Memorandum submitted by the Mae Tao Clinic, The Back Pack Health Worker's Team and Burma Medical Association

SUMMARY

¹We 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.

²We 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.

³At 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.

⁴SPDC'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

⁵That 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 organizations 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

· not support government development projects which are likely to result in human rights abuses

WHO WE ARE

⁶We 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.

⁷All 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

⁸We 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 1 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 2 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.

⁹The 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 1000 live births)	Under 5 Mortality Rates (per 1000 live births)
Eastern Burma conflict zones	91	221
Burma national rates (UNICEF)	76	106
Thailand	18	21
Angola	154	260
Congo (DRC)	129	205

¹⁰These 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 1 in 5 children will not live to see age 5, and 1 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.

¹¹The 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

¹²The following table shows that 1 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.

	MMR Per 100,000 live births	Lifetime Risk of Maternal Death ( 1 in xx )
Eastern Burma conflict zones	1000-1200	12
Burma	360	75
Thailand	44	900
Congo	990	13
Somalia	1100	10
Rwanda	1400	10

¹³This 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.

¹⁴Ethnic 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.

¹⁵Mae 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	107137	48%
Referral	675	66%
Blood Transfusion	1480	71%
Tubal Ligation	177	72%
Eye Surgery	274	86%
Malaria (PF)	6088	75%
Severe Malnutrition	47	61%
ANC Client	4069	29%
Delivery Admission	1798	40%

¹⁶The 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

¹⁷Several donors have been supporting effective local community and civil society organizations that have initiated programs to provide healthcare and education in cease-fire and non cease-fire areas, to address the humanitarian crisis. Community organizations manage their own clinics, mobile health teams and schools unassisted by the SPDC. As well as the work of the organizations 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 organizations provide vocational skills training, literacy training, health education and relief to women and children living under the regime. The women's organizations 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 organizations 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.

¹⁷Donors 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.

¹⁸Some 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.

¹⁹Our organizations 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.

²⁰There 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.

²¹Any 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 organizations 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.

²²It is essential that there is a focus on strengthening human resources at a grassroots level with community managed organizations, for the long term development which is based on the actual needs of the people.

²³The 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 orgs, 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

²⁴The 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.

²⁵The 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

²⁶The 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 2 to 5 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

²⁷The 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.