Examination of Witnesses (Questions 57-59)
DR THOMAS
LEE
7 JUNE 2007
In the absence of the Chairman, John Battle
was called to the Chair
Q57 John Battle: Could I welcome you,
Dr Lee. I know you are in London for a conference at the present
time all the way from your work at the Los Angeles School of Medicine.
Can I thank you for taking the time and trouble to come and share
your experience with us in our evidence session. I wonder if I
could start by perhaps asking you in general terms to say what
you think the particular healthcare needs of the IDPs are and
what are the major challenges in meeting those needs from your
long and rich experience of being there on the ground. If you
would like to give us some opening remarks we can then perhaps
tease out some of the issues around healthcare, violence and the
future.
Dr Lee: I have been working on
the different borders of Burma for about 10 years now, mostly
Thai-Burma but also the India-Burma and China borders. One of
the most important problems we have been dealing with is the problem
of infectious disease, which also gets the most attention from
the international community. In eastern Burma there is no question
that the number one cause of morbidity and mortality is malaria.
We conducted some scientifically standard assessments of malaria
over the last several years, and I have provided some papers on
that[7].
Approximately one in four children in eastern Burma die before
the age of five and about 55% of those kids die from malaria.
It is an extremely high burden of disease. We have begun to do
similar studies on the China border and we are finding that the
malaria burden there is perhaps even higher. The same is true
of the western border with India. HIV is also a significant problem.
In Thailand the rates have been comparable with what has been
measured inside Burma. We have rates in pregnant women of between
1 and 2%. On the China and India borders the HIV problem is much
worse, primarily because of the trafficking of heroin and injecting
drug use. We are seeing the problem there is much more extreme.
The HIV rates on the Burma border are the highest in India and
China in those countries on the borders. The third problem is
tuberculosis. On the Thai border not only are we seeing that most
cases of TB are seen in Burmese migrants but they also have a
much higher rate of drug-resistant TB which is of huge international
concern. In fact, last week there were three ex-pat workers in
a refugee camp in Thailand diagnosed with extreme drug-resistant
TB (XDR TB) which has got a lot of press recently, I do not know
if you have heard this. That has significant implications for
the management of TB on that border. Also we are seeing a lot
of TB on the China and India borders because part of what is driving
that is the co-infection with HIV.
Q58 John Battle: What is the response
to meet those challenges in terms of personnel and money?
Dr Lee: I think the primary limitation
has been resources, funding. On all three borders there are substantial
indigenous local health organisations that do have the infrastructure
and the capacity to provide standard interventions for infectious
disease. For example, on the Thai border we are conducting perhaps
the largest malaria programme ever conducted in the cross-border
regions there. There are dozens of Back Pack Health Worker Teams
which receive the highest profile and attention but there are
also dozens of clinics run by the Karen, Mon, Karenni and Shan.
On the China borders we are working with the Kachin health department
and a Palaung health organisation and on the Indian border with
Chin, Naga, Kuki and Zomi. There is a very large indigenous health
programme that I think is unrecognised and severely under-funded.
In eastern Burma, for example, with some malaria programmes, historically
they have had to use second rate drugs that are not as effective.
The Back Pack Health Workers, for example, use quinine-tetracycline
combination anti-malarials which are known to be much less effective
than what we call artesunate combination therapy. That is primarily
a funding problem. I have seen claims that the efforts on the
Thai border, for example, are well-funded, or fully funded, and
I would like to say that is ridiculous. If you look at our malaria
budget, for example, in eastern Burma over 80% of the budget is
for anti-malarials, rapid diagnostic tests, and insecticide treated
nets--just for commodities. That gives you some idea that the
budget is very thin, very shoestring, there is very little money
left over for other aspects of the programme that are important:
health worker salaries, transportation, logistics.
Q59 Ms McKechin: I wonder, Dr Lee,
how can donors such as DFID best address the link with human rights
abuses, of which of course there are many in many different ways:
people being deprived of food when they are thrown out of their
villages, the sexual abuse of women and forced labour? We met
refugees who had been subjected to forced labour with very detrimental
effects on their health. How should donors try and target aid—is
it to try to concentrate aid-giving around the border camp areas
as well as trying to boost the health authorities within Burma
itself?
Dr Lee: We conducted a study in
eastern Burma which basically measured the impacts of human rights
violations committed at a population level on population health
indicators. I do not know if you are familiar with that. That
was published in the Chronic Emergency report by the Back
Pack Health Workers, but we also will have a scientific publication
coming out in one of the British Medical Journals which I provided
beforehand. Basically what the study demonstrated was that human
rights violations, such as forced displacement, food insecurity,
disruption of food resources and forced labour, were one of the
most significant determinants of health. For example, in families
that had been forced to move the chance of a child dying in those
families was about 2.8 times as great as in families who were
not forced to move. In terms of mitigating that impact of the
human rights violations on health the most obvious would be to
stop the human rights violations and obviously that is difficult.
To get the military to stop forcing villagers to move in eastern
Burma would be difficult. Secondary to that the best thing we
can do is to make sure there are enough resources there to deal
with the problems that come as a result of forced displacement.
When people are forced to move they are more likely to catch malaria,
they do not have access to health resources, they are more likely
to get diarrhoea, they are more likely to be malnourished and
they are cut off from their food supply. I think the organisations
working on the ground there have to have adequate resources to
respond to those human rights violations.
7 Unprinted background paper submitted by Dr Thomas
Lee Back
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