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What do I have? What is the cause of my sickness? How did I get sick?
We dont just get of my sickness? sick: look closely What is the cause to see the problems (context)
Child with jaundice, Papun District, January 2008 Photo: Karen Human Rights Group
A smooth transition?
Not everything that counts can be counted, and not everything that can be counted counts.
Albert Einstein
Aung San Suu Kyi, Khun Htun Oo, Aung Din, Dr. Cynthia Maung and Kyaw Thu, NED awards, Washington. September 20, 2012. (Photo: Reuters)
Thailand 11 13 7
Burma 50 66 23
2 3 8
(2008)
(2006-2010)
100 (1998)
99.5 (2009)
63.9 (2007)
---
Source: Millennium Development Goals Indicators 2010, http://mdgs.un.org, (Figures for 2010)
Singapore
Govt expenditure on health per capita Private expenditure on health, %THE Govt health expenditure, % general govt expenditures
Thailand $134
Burma $2*
$629
63.7
25.0
87.8
8.0%
12.7%
1.0%
IT DOES NOT COST A LOT TO SAVE THE LIVES OF MOST MOTHERS AND CHILDREN
Vaccine-preventable diseases
2011 2010 2009 2008 2007
Burma:
5 Priority: Malaria, HIV/AIDS, Tuberculosis, diarrhea, malnutrition The principal endemic diseases in Myanmar are cholera, plague, dengue hemorrhagic fever, watery diarrhea, dysentery, typhoid
Ministry of Health, Country Health Profile, WHO/SEAR
Burmas statistics
1. Public 2. The borders Health in are even worse Burma notin This is is a Crisis coincidence
The burden is borne (beware by moms and of national especially level figures) children
Eastern Burma
Neglect of social services, worse poverty Civil war, abuse, development
Since 1996, >3700 villages destroyed, moved Abuses common: forced labor, seizure property/ land, destruction food, torture, rape, murder Mainly ethnic, fuels largescale migration:
IDPs Refugees migrant workers Highland permits
Home destroyed by tatmadaw, July 23-24th, 2010, Papun District. Photo: KHRG, July 27th 2010.
7 year old injured in SPDC attack on village, Papun District, June 2009. Photo: KHRG
Fleeing SPDC village attack, destruction in Nyaunglebin, Karen State, January 2010. Photo: KHRG
Forced Labor: February 23, 2010, boy from Bu Tho Township, Papun District, carrying thatch shingles to meet order issued by a local Tatmadaw unit. [Photo: KHRG]
April 2012: Forced labor (ploughing, planting paddy) for Burmese Army, on seized farmland. Karen State. KHRG, July 2012
Landmines: March 2010, 46 year old villager injured by landmine while working in plantation, Toungoo District. Fellow villagers construct stretcher and carried him to the nearest medical facility, 2 hours away on foot. [Photo: KHRG]
For every civilian killed, injured directly by the army, many more suffer/ die indirectly, due to Seriously of the regime, especially mothers (in)actions ill schoolgirl, being carried to nearest clinic (several days walk away). KHRG, 2006. and children. (Malign neglect)
DIAGNOSIS: CRITICAL
Health and Human Rights in Eastern Burma
Survey: Sampling frame >325,000 Randomly sampled 5,754 households (27,802 people) Covered 21 rural townships Builds upon previous surveys
750
71
138
108
54
73
69
Surveyed 27,802, 21 Townships 60% of deaths in children under 5 from preventable & treatable diseases.
Malaria
Malaria: 27.7% deaths (#1) for children under five.
Diarrhea: 17.2% ARI: 14.9%
MOM Project
Mobile Obstetric Maternal Health Worker Network, ethnic, community RH workers Sampled almost 3000 IDPs, 2006
Births attended by skilled personnel 1 antenatal visit Unmet need for family planning
97.3 (2006)
57 (2001)
97.8
75.6
39.3
(home TBAs or CBO clinics)
3.1%
19.1%
61.7%
MOM Project:
3000 IDPs, E Burma 2006
Thailand Burma IDPs, eastern Burma
5.1
Births attended by skilled personnel 1 antenatal visit Unmet need for family planning
97.3 (2006)
57 (2001)
97.8
75.6
39.3
(home TBAs or CBO clinics)
3.1%
19.1%
61.7%
MOM Project:
Karenni (ceasefire): 32.3% forced labor Karen (conflict): 10.5% forced to move Shan (conflict): all, >20%: food insecurity, forced labor, forced relocation, attacks by authorities
2.5 1.9
Outcome
Child death No contraception Mod-severe acute childhood malnutrition
Increased Odds
1.7 9.1 3.3
Food insecurity
11.7%
1.8
1.6
Systematic Failures:
Health Impacts of Violations
Forced displacement: Outcome
Child death [BPHWT] Child malnutrition [BPHWT] No antenatal services [MOM]
Increased Odds
2.8 (1.04-7.54) 3.17 (1.76-5.72) 5.94 (2.23-15.8)
Increased Odds
1.5 (1.1-2.3) 2.0 (1.3-3.1) 1.8 (1.2-2.9)
Conclusions:
IDPs in eastern Burma facing a large-scale humanitarian crisis
Health measures worse than Burmas official statistics Decades long & continues
HR abuses by regime against civilians widespread Closely linked to mortality and morbidity
Malaria analogy: must address root causes
Homes destroyed in July 23-24th Tatmadaw attack on Tha Dah Der village. [Photo: KHRG]
Malaria in Burma
Malaria is one of the priority diseases in Myanmar. It is re-emerging due to climatic and ecological changes, uncontrolled population migration, development of multi-drug resistant P falciparum parasite Long-term trend shows decreasing malaria morbidity and mortality in Myanmar.
Ministry of Health, Health in Myanmar 2010
70% population in malaria-endemic areas Esp borders: Chin, Karenni, Kachin #1 cause of death; 1/14 women HH heads had Pf (DC 2010) Chin: unofficial surveys- up to 25% people infected No access high risk resistance: artemesinin Issue of underreporting
12,696 15,906
2007, Health Information Systems Working Group Target population: ~380,000 Cambodia 40,500 cases malaria diagnosed Source: Department of
Disease Control, Ministry of Public Health, Thailand, 2003
Lao PDR
1. Tak (8,261)
Myanmar
4.Kanchanaburi (1,099) 10.PrachuapKhirikha n (616) 6.Chumphon (896)
4 9 10
8 7
7.Si Sa Ket (687)* 8.Surin (651)*
Cambodia
9.Chanthaburi (646)
2.Yala(2,077)
2 5 Malaysia
5.Narathiwat (1,019)
Source: Malaria Cluster, Department of Disease Control, MOPH.
Clements A, Barnett AG, Cheng ZW et al. Space-Time Variation of Malaria Incidence in Yunnan Province, China. Malaria Journal 2009; 8: 180.
It would certainly compromise the idea of eliminating malaria that's for sureclear evidence that parasite clearance and will probably translate into a resurgence of malaria in many placesIf we were to lose artemisinin then we don't have any responses after artesunate are slowing on new drugs in the pipeline to replace them. We could be going back the northwestern border of to treat because 15 years to where cases were very difficult Thailand. of the lack of an efficacious drug Francois Nosten, SMRU
Many examples
Break time?
3. These failures threaten not 4. These failures are only the peoples of Burma especially dangerous now
Current health failures indicative Supporting incapable to respond of a system this system (a failed state) to infectious diseases, may be bad for your health humanitarian disasters
Area, popl off-limits to aid organizations, UN 87% at risk reached BUT we could reach only three [out of 4] areas because of security.
Saw Eh Kalu, KDHW
Reference: Zhang Y, Ding Z, Wang H et al. New Measles Virus Genotype Associated with Outbreak, China. EID 2010; 16(6): 943-947.
Vaccine-preventable diseases
2011
Vaccine-preventable diseases
2011 2010 2009 2008 2007
Cholera
Swaddiwudhipong W, Ngamsaithong C, Peanumlom P, Hannarong S, An outbreak of cholera among migrants living in a Thai-Myanmar border area, J Med Assoc Thai 2008; 91(9): 1433-40.
Surveillance around Mae Sot May-Oct 2007: 477 cholera cases found in Mae Sot District, Tak 84.9% Myanmar migrants
Who is to blame?
Emerging Threats: Pandemic Influenza Avian Flu (H5N1), Swine Flu (H1N1)
2004: young Shan migrant worker with leg pain, swelling, fever Chiang Mai city Presents to clinic
Concern for malaria blood smear
Lymphatic filariasis
Parasite Over 120 million worldwide infected Major cause of disfigurement and disability; severe psychosocial and economic impacts Deaths: secondary infections
Clinical filariasis
Most infected have no symptoms, but can infect mosquitoes
Diagnosis: blood test
Only a few get late complications: lymphedema (swelling due to chronic inflammation of the lymph vessels)
Chronic changes: too late
Prevention of filariasis
cornerstone: mass treatment (MDA): reduces transmission AND morbidity in community
Longterm, decrease infected people inability to sustain transmission
>80% 4-6 yrs
WHO: once per year treatments 5 yrs or until treatment interrupted. (DEC+albendazole)
12 10 8 6 4 2 0
92 19
11.16 6.54 5.78 5.54 3.27 2.28 1.45 0.99 0.71 0.58 0.53
93
94
95
96
97
98
99
00
01 20
19
19
19
19
19
19
19
20
Year
- Covers entire nation (all at risk areas w MDA) - 185 new reported cases in 2002
20
02
Systematic FailuresMongnai
Filariasis Endemic Areas and Areas Under Mass Drug Administration, 2006
LF Endemic (45 Districts; 40m)
- Almost all: migrants from Burma - Cross-sectional surveys of migrants in Mae Sot: 4-10% - Capable vectors in urban Thailand: just need more infected
Reference: Triteeraprapab et al. High Prevalence of Wuchereria bancrofti Infection Among Myanmar Migrants in Thailand. Ann Trop Med Parasitol 2001; 95: 535-538.
(Old) migrant worker registration system: filariasis evaluation during health examination (Great!)
~1M legal Burmese migrant workers in Thailand; NV & temporary passports for ~750,000 (Sept 12) Unregistered, illegal migrant workers ???
2004: 2 symptomatic patients found in Chiang Mai city Both Shan migrant workers.
4.6%
338/865
39%
LF Nonendemic (19Districts; 12.9m)
Mongnai
From: Salween Watch, SEARIN, Chulalongkorn U. The Salween Under Threat, October 2004.
Tasang Dam
Salween: longest free river in SEA 228 m tall, highest in SEA, $6B 7,110 MW installed capacity
Mostly to Thailand Flood zone: 870 sq km (SG: 697)
PH impact?
130 km from Chiang Mai
Source: Beyrer C, Villar JC, Suwanvanichkij V, Singh S, Baral SD, Mills EJ. Neglected Diseases, Civil Conflict, and the Right to Health. Lancet 2007; 370: 619-627.
Thailand
Aid per capita Govt health expenditure per capita Govt health expenditure, % general govt expenditures Gen govt expenditure on health as % THE
Burma
Laos
Cambodia
-$134 12.7%
$10.8 $2 1.0%
75.0%
12.2%
33.3%
37.2%
All figures from 2010 (save aid). Sources: WHO, http://www.who.int/nha/country/en/; UNDP, Human Development Report 2010
The money myth #1 producer natural gas, Asia (Burma aint broke)
Estimated current foreign reserves: >$3 billion
Moved 11-11-05, 11 AM, 1100 trucks, 11 battalions, 11 Ministries >$5 billion; $122244 million/yr (IMF) "How much it cost is not that important What is important is not to have a budget deficit."
BG Kyaw Hsan, Information Minister (April 2007)
FEBRUARY 2006
- list of local staff working in Myanmar shall be provided - will coordinate for the travel programme and will accompany them in the trip. - The UN Agencies, International Organizations and NGOs/INGOs shall refrain from the activities not within the scope of the work the respective organization shall seek the prior approval from the concerned Ministry. - INGO restrictions tightened, January 2008: liaison officer/travel, data collection: pure health activities to get MOUs - visa restrictions even before Nargis, expulsion of UN Resident Coordinator for criticism of regime (Nov 07)
GOOD GOVERNANCE
(Durable public health change remains distant)
K7.98T; no parliamentary Health: 2.8%, $450M oversight (quadruple) we cannot talk about it Education: 4.7%, openly now as its a $750M (double) sensitive matter to
discuss. (Anonymous MP)
Current waitlist of ~200 with MDR TB waiting for treatment, do not make it to official statistics.
MTC positions RE Myanmar Peace Team Thus far, serious discussions to begin the realization of this [a comprehensive primary healthcare system] in ethnic areas of Burma have yet to begin.
1) Improvement in cross-border collaborations between health services in Burma, Thailand: referral system between Myawaddy Hospital, Mae Sot Hospital, MTC 2) Accreditation and recognition of health staff on the Thai-Burma border 3) Stateless children born on the Thai-Burma border to Burmese parents, especially at MTC, MSH
Abuses: forced labor (porters), rape, torture, extrajudicial killings reported; political prisoners ~100,000 estimated displaced; aid blocked by Burmese govt
7-10,000 to China; Aug-Sept 12: ~5000 deported Communities forced to rely on CBOs: UN, INGOs provided ~4% IDP needs Jun 11 Aug 12
Shan: SSA-S
Ceasefire (Dec 11), peace deal (May 2012), Kengtung
>30 clashes since
SSA-N (SSPC) [Ditto] we feel like we are second class citizens we dont have equal rights. How can we go on? (Hso Ten, SSA-N) Civilians: abuse- rape, torture, porters
Displaced: >3000
Surveyed 665 HH, 82 villages, Jan 11 Jan 12 30% suffered HRV within 1 yr
Forced labor: 26%
porters: 15%
torture, kidnapping, sexual assault: 1.3% Forced displacement rare but 01-11: >30% Development: Tavoy (govt) worst: 2.4X odds forced labor 4% knew of ILO, 0.7% reported (Access)
PHRs survey of human rights violations and humanitarian indicators in Karen State shows that human rights violations persist despite recent reforms on the part of President Thein Sein. Of particular concern is the prevalence of human rights violations even in areas where there is no active armed conflict, as well as the correlation between economic development projects and human rights violations.
Rohingya: June 12
800,000 forgotten people No citizenship abuse, discrimination
Bengalis, kala Bangladesh: 200,000
Strife: (>)78 killed, >115,000 displaced Crackdown, State of Emergency mass arrests (young men), violence, rape, destruction property Thein Sein solution No outside observers (journalists), relief restricted
Rohingya
811 destroyed structures, Kyaukpyu, Oct 24
Kaman Muslims: recognized as citizens Religious war?
Healthy skepticism
(Member of Parliament DASSK, BKK, June 2012)
Improving public health: must also improve civil society, empowerment, encouraging good governance
Respect for rights!
No borders can stop health problems; health & other programs should not respect borders Prevention is best: incremental costs to address epidemics
Encouraging rights, bringing good governance can be best form of public health prevention
Cannot focus on one face alone! Good governance, respect for rights= good health policy
PH problems can indicate failure: need to go beyond traditional responses Politicizing health myth
Thank you!
Links
Backpack Health Worker Team: www.backpackteam.org Mae Tao (Dr. Cynthias) Clinic: www.maetaoclinic.org Global Health Access Program (GHAP/CPI): http://cpintl.org/ Karen Human Rights Group: www.khrg.org SWAN: www.shanwomen.org US Campaign for Burma: www.uscampaignforburma.org Thailand Burma Border Consortium: www.tbbc.org PHR: http://physiciansforhumanrights.org Center for Public Health and Human Rights, JHU: www.jhsph.edu/humanrights