Examination of Witnesses (Questions 60-79)
DR THOMAS
LEE
7 JUNE 2007
Q60 Ms McKechin: That is more capital
intensive because you need more drugs like anti-malarials?
Dr Lee: Yes. It is a question
of resources. There are some capacity limitations, there have
to be, but I think there should be more training, more technical
support. The aid cannot be given without that support but the
primary limitation is the resources.
Q61 Sir Robert Smith: When we were
there we did hear in briefings about the cross-border healthcare
and that there were attempts to provide community health improvements
as well as direct emergency assistance. What sort of proportion
of the cross-border aid provided by the mobile health staff do
you assess is going to go on basic first-aid assistance and on
providing preventative medicine and health education?
Dr Lee: There has been a gradual
shift over the last 10 years in the type of aid that is provided.
Initially when these organisations were just getting off the ground
they were just trying to treat disease, treat malaria, diarrhoea,
dealing with landmine injuries, and they evolved over time to
more preventative care, school health education, community health
education and prevention programmes, water, sanitation, latrines.
It is pretty hard to estimate the number because a lot of the
programmes deal with both. It is kind of an artificial distinction
in some ways but I would say 50%, and that is growing. There is
a growing recognition by Dr Cynthia and the health workers there
that they really have to build the capacity of the local people
to provide healthcare for themselves in order to really have an
impact. For example, with malaria treatment, as these Back Pack
Teams move around and provide treatment what they have found is
that it is more effective to train the villagers to diagnose and
treat malaria themselves instead of having to be there because
they cannot always be there, they are hunted down by the military,
they are always moving. If they call on the village to help with
volunteers and healthcare workers then they are more effective
in terms of having an impact on health status.
Q62 John Bercow: Dr Lee, I would
be interested to know what you think are both the prospects and
the problems for the Three Diseases Fund—what it can do
but also what perhaps it simply cannot do, not necessarily because
of a shortage of resources but because of the political climate
within which it is operating. Specifically, I am quite interested
to know how you think donors can be confident, if they can, that
regime restrictions on their operations, the requirement for a
Memorandum of Understanding and so on, will not cause the Fund
to face the same premature closure or dissipation that affected
the Global Fund?
Dr Lee: There has been a lot of
discussion about the comparative advantage in terms of the 3D
Fund and other donors working inside versus on the borders. If
you look at the areas that have the highest malaria burden of
the country, for example—I wish I could show a slide, I
asked if I could show something here—the areas of the country
that have the highest malaria burden are along the four borders.[8]
It is not a thin band, it is a wide band, wide regions that have
extremely high rates of malaria. If you look at a map of the areas
where the INGOs[9]
working inside have access, the map is somewhat the inverse. The
map that shows where they are working and where they have access
to looks like this, and the risk areas are around that area. It
is not clear to me that those organisations will be able to effectively
target not only the most vulnerable populations but also the areas
that have the highest impact on the neighbouring countries in
terms of the spread of infectious disease.
Q63 John Bercow: So the Fund, in fact,
will meet the needs in whole or in part of less vulnerable people,
still highly vulnerable but less vulnerable, than those of whom
you have got direct experience?
Dr Lee: Sure.
Q64 John Bercow: What measures, in
your judgment, are required to reduce the incidence of malaria
amongst the IDPs? Is the problem, and I say this as a lay person
looking for guidance from an expert, a lack of prophylactic medicine
and nets, or is the difficulty one that lies in either the distribution
or the uptake, or is it a combination of both?
Dr Lee: Just to give you an example,
on the eastern border we are working with Back Pack Health Workers
and also the Karen Health Department. Their population coverage
is about 260,000 people. We have only been able to implement malaria
control programmes with about 40,000 of those people, so less
than 20% of the population there. The methods that we have used
are just standard methods recommended by the WHO. We have rapid
diagnostic tests, microscopes, anti-malarials, insecticide treated
nets, it is not anything that complicated. In the populations
where we have the resources to implement those types of programmes
we have documented a dramatic decline in the malaria rate, so
it is possible to have effective programmes in these areas if
we have the resources. We have a paper being reviewed in a journal
called Conflict and Health which shows those rates coming
down. I have to say that because of the concerns about cross-border
monitoring we have had to have levels of monitoring that go beyond
what usual aid agencies are required to have in areas they work
in, say, in Africa or other countries in South East Asia. The
same is true of TBBC—they have to take a picture of every
family that gets a basket of rice because of extreme concerns
about cross-border monitoring. The methods are there and the tools
are there, it is just a matter of resources.
Q65 Ann McKechin: Can I just ask
how many people do you think are in this outer ring of high risk,
how many do you think we may be talking about in the population?
Dr Lee: If you look at just the
sheer numbers of ethnic minorities versus the Burmese, in the
centre of the country it is something like 50% of the population
is composed of ethnic minorities. There are some areas that are
in these ethnic states that the organisations working in Rangoon
can reach. I am not saying they cannot reach any of these at all
but it is—
Q66 Ann McKechin: It is patchy.
Dr Lee: It is very partial and
it tends to be in the towns. If you look at where they actually
have access it is in the urban areas where the government has
control. The tools are there. We are employing the exact same
tools on the China, India and Burma borders: diagnostic tests,
medicines and nets. It is very simple. When we get those we provide
training for the health workers there, we train the organisations
to do monitoring and we get the supplies out into the field, it
is very simple.
Q67 John Bercow: Finally, I am interested
to ask you about co-ordination and what co-ordination exists between
Burmese public health ministries, the NGOs and the community groups
to work on infectious diseases. How robust is that co-ordination?
I suppose at the back of my mind, although you may be able to
allay my concern, is an underlying concern that we are talking
about Burmese government organisations, Burmese departments, having
a role in co-ordination and these Burmese departments are departments
of the government that is committing the atrocious human rights
abuses that are themselves a contributory factor to some of the
disease.
Dr Lee: I think that is very true.
On the one hand, in Karen State, for example, you have the military
coming in and displacing tens of thousands of people and I think
the local organisations on the ground, the people on the ground,
find it strange that on the right hand of the government they
are committing these atrocities, forcing people to move, and then
on the left hand they have money to come in and provide health
aid. It is very strange because to them it is the same organisation,
it is the Government. They have government organised NGOs which
are basically government organisations providing humanitarian
assistance but on the other hand they are also causing the problem.
It is very confusing to organisations on the ground there.
Q68 Richard Burden: Could I ask you
a little bit about the health data. The data you have given us
so far has been very helpful about the arc around the centre of
the country but there are big differences, are there not, between
the figures that the Burmese Government produces for health indicators
and those that others, particularly the Back Pack Health Worker
Teams, have produced. We understand they are quite staggering:
overall mortality one and a half times higher amongst IDPs, landmine
injury and death four times higher, malaria incidence nearly twice
as high and one in 12 women IDPs likely to die in childbirth,
from the figures that the regime comes up with. What do you think
donors could do to try to get the collection of accurate data
on a firmer footing, whether that be in-country or whether it
be through supporting workers, Back Pack Health Worker Teams or
others?
Dr Lee: The reason there is this
discrepancy is that it is a question of access. A lot of the figures
from inside come from, say, UNICEF where they are documenting
child mortality rates. It is not their fault, they cannot access
the areas that have higher child mortality, so they are not misreporting
data, it is just a lack of access. If the international community
is really interested in knowing what the true extent of disease
is and mortality and morbidity then they have to support organisations
that can access these areas and measure these types of numbers.
We hosted an infectious diseases conference in Bangkok in January
with organisations from the borders and from inside. We had Charles
Petrie, the UNDP and UNAIDS there to try to figure out if we could
communicate, because there is very poor communication between
inside and outside organisations, to try to come up with some
disease surveillance systems, to collaborate together on measuring
disease in these border regions where there is so little information.
There has to be greater support for that effort and there also
has to be greater communication between the groups on both sides.
Q69 Richard Burden: Were there any
specifics that came out of those discussions, without compromising
anybody, that you can share with us today where you could say
this is something that could be done in terms of improving co-ordination
and communication, or this is a particular project which could
do with more support, whether it be from DFID or DFID asking someone
else to support it?
Dr Lee: We have a plan to host
border specific meetings that include groups working on both sides
along each border. We would like to host collaborative meetings
and conferences in Bangladesh, India, China and Thailand where
the relevant parties, both the local community-based organisations,
NGOs and regional government organisations, come together to meet
and discuss the collection of information and reporting of information.
We are hopeful that this effort will be successful. We have come
up with a proposal and we are hoping to be able to raise support
for that.
Q70 Richard Burden: Just to clarify,
in that context who is the "we" that would do the hosting
and where has the proposal gone?
Dr Lee: The group that sponsored
the conference in January was the Open Society Institute, the
OSI, but by the "we" I guess it is a collaboration of
universities, there is the Centre for Public Health and Human
Rights at Johns Hopkins University, the Centre for Human Rights
at the University of California, Berkeley, my organisation, the
Global Health Access Programme, and working together with some
organisations in Thailand. We would like to work with the organisations
inside, like the UNDP, UNAIDS, and I have to say that they have
been open to the idea of attending these conferences and participating.
I think they also realise there are constraints that they have
inside that they need to try to overcome.
Q71 Ann McKechin: The Committee is
obviously concerned that the International Committee of the Red
Cross has had to close two of its field offices in eastern Burma
recently. What do you think the impact will be of the closure
of those offices in terms of health in that part of the country?
Why do you think that the ICRC may have been singled out in particular
among international organisations by the Burmese authorities and
has that had any implication in terms of making it more restrictive
or curtailing what you are actually doing or contact with the
Burmese authorities on the issue of health specifically?
Dr Lee: I do not think the ICRC
was really singled out, I think that restriction has been placed
on most of the INGOs working in Burma. There was a general increase
in the level of restrictions after the sacking of Khin Nyunt,
the head of the military intelligence programme. In terms of the
impact on health, ICRC was not conducting large scale health operations
in those areas but I think they played a significant role in witnessing
potential human rights violations that would impact health. That
would be the primary impact.
Q72 Ann McKechin: They had a monitoring
role in terms of overall health of the population. Was the information
that they provided of use to people and what will be the impact
of the fact that you have lost that independent voice or presence?
Dr Lee: Yes, their pull-out will
be very damaging in that aspect, especially with respect to the
health of political prisoners. They played a very important role
in monitoring that. I have heard rumours that other INGOs are
considering pulling out and that would have a drastic impact on
the health of people there.
Q73 Sir Robert Smith: DFID provides
some funding to the World Health Organisation: £1.5 million
over three years to a programme aiming to achieve sustainable
improvement in the surveillance of preventable diseases, such
as measles, and another programme of £500,000 over five years
to support the provision of healthcare to unregistered refugees
on the Thai border. There are other funds as well. How effective
is the World Health Organisation in support to IDPs in Burma,
including on the borders?
Dr Lee: I have to say I have been
on the border working there for 10 years, working with IDPs, and
the WHO inside Myanmar, and also the WHO in Thailand, has not
been involved in any kind of data collection relating to IDPs
in Burma.
Q74 Sir Robert Smith: Do you think
a large organisation is not really the right vehicle and that
community-based groups are more likely to be able to do that?
Dr Lee: I do not mean to single
them out. What is really true is that there has been no-one involved
in supporting that effort. In general the IDP effort has been
funded mostly by small private donors, foundations, church groups,
that sort of thing. The organisations that work in Thailand which
are registered to work there and have any links with the Thai
Government are not officially allowed to engage in cross-border
activities, it puts their MoU in Thailand at risk. Similarly,
organisations in Burma have the same restrictions. That is why
for the most part they are not allowed to work openly with IDPs.
Q75 Sir Robert Smith: In a sense
do you think they have to make that choice then that either they
work with IDPs or work in the way they are currently working?
Dr Lee: Yes, it is a choice they
have to make: are they willing to put their programmes at risk
in the country to work with IDPs. Sometimes it is not a black
and white thing. There are many organisations that push the borders
of their MoUs by working quietly cross-border and also there are
groups inside that quietly push the borders of where they are
actually allowed to work quite effectively. Some organisations
are more aggressive about that than others.
Q76 John Bercow: Dr Lee, the Mae
Tao Clinic in Mae Sot, Thailand, provides free healthcare for
refugees, migrant workers and other Burmese people who have crossed
the border to Thailand, but, of course, doing so involves a journey
that can be difficult, lengthy, expensive and dangerous. Do you
feel, nevertheless, that donors, such as DFID, should support
clinics in border areas? If you do, how do you answer the charge
from others that this serves only to encourage IDPs and refugees
to make those journeys which, as I say, are long and risky?
Dr Lee: It is true. At Mae Tao
Clinic, for example, last year they treated approximately 8,000
patients with malaria and 75% of those patients came from Burma.
There is no question that donors need to support that. If we could
set up support systems inside that would be better, but right
now that is not the case. In terms of the amount of support, the
number of donors who are willing to cross the border, it is much
smaller than the number of donors who are willing to support the
Mae Tao Clinic, refugee camps and clinics operating on the Thai
side.
Q77 John Bercow: So you are working
with what is on a practical basis and on that line of argument
you say—I do not seek to put words in your mouth, I seek
to extract them—"let us work with what is and try to
make it better"?
Dr Lee: But let us also try to
reach out and set up improved systems across the border as well.
Q78 John Bercow: I am sorry to press
you but there is no doubt that it is a recurrent theme in our
inquiry, and you expressed yourself very robustly and explicitly
at the outset in saying that the idea that there was sufficient
being done on the borders and no more could be done was wrong.
I think you put it rather more strongly than that. Just so I am
clear in my own mind, are you arguing on the strength of your
own personal experience that a greater resource should be devoted
by the Department for International Development, which it is our
duty to scrutinise, to the provision of cross-border assistance?
Dr Lee: Yes, definitely. That
would go not only for the Thai border but also China and India
as well. I was happy to learn that DFID is supporting some efforts
on the China border and I have to say that USAID, for example,
and other donors who are more restrictive in the kind of support
they can give will often limit themselves to Thailand and often
limit themselves to activities in Thailand. If DFID and other
donors were able to be more flexible and to reach out to these
other borders and just to the vulnerable populations the aid would
be much needed and very well received.
Q79 John Battle: When some of us
visited the Ban Mai Nai Soi Camp, there was the Ban Tractor Health
Clinic that we visited there, which was a busy little place. I
know it was an official visit and it was likely to be full that
morning but they were dealing with the daily problems of people
who were refugees, problems with breathing—I am not a doctor—respiratory
problems, urinary tract problems. If they had anything serious
they had to get there from a few hours away through difficult
terrain and if it was raining it would have taken them some time.
I thought it was a clinic that was doing well under pressure really.
I would like to hear from you a last remark. If you were to stress
to us what should be in our report in terms of recommendations
to DFID and the British Government, just as Mark and Ben commented,
and you heard their evidence before, I am left with the strong
impression of resources and trying to work through the difficult
business of resources and how to do the inside and the outside,
cross-border, what would be your particular suggestions to us
that we should recommend to ensure that the healthcare challenges
in the refugee camps are addressed today, next month and for the
next few months, and perhaps the next year or years until this
political situation is properly tackled?
Dr Lee: One would be, as I have
already said, increased resources. Those resources need to be
combined with enough support for training and capacity building
of the organisations and the health workers, and also technical
support. What I have sometimes seen is aid being provided without
the resources for technical support and training of the local
organisations. The second would be that the support comes unrestricted
or with less restrictions than has been provided in the past.
I will give you an example: USAID recently committed $3 million
for cross-border support this year and $1 million for health.
None of the funds could be used for medicine, none of the funds
could be used for rapid diagnostic tests for malaria and none
of the funds could be used for insecticide-treated nets. That
is 80% of our budget. Other restrictions included that all supplies
must be bought in Thailand. For example, if you are building a
cement latrine you have to buy the cement in Thailand and carry
it on your back across the border. So not just an increase in
resources but some freedom in terms of how those resources are
used. As I mentioned before, there is also a problem in the restriction
of those funds to the Thai border, where there is already significant
support, in comparison with the Indian and Chinese borders.
John Battle: If there are no other particular
questions, can I thank you most sincerely for your evidence and
the detail of information that you have compacted into it. It
has been a really valuable session. We thank you for giving us
your time this morning.
8 Unprinted background paper submitted by Dr Thomas
Lee Back
9
International non-governmental organisation (INGO). Back
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