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Why do we get sick?

Burma, state-building & health


Voravit Suwanvanichkij, MPH, MD
CENTER FOR PUBLIC HEALTH AND HUMAN RIGHTS

Johns Hopkins Bloomberg School of Public Health

November 12, 2012

Why do we get sick?


I dont feel well today. I have a cough, fever, and runny nose. I am sneezing all the time.

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

The (structural) context


(Bad) health does not just happen: Burma, when things fall apart

A smooth transition?

Source:The New Light of Myanmar, January 3, 2011

Source: The New Light of Myanmar, January 15, 2008

Source: The New Light of Myanmar, January 15, 2008

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)

Healthy skepticism towards


(investment) in Burma
(DASSK, World Economic Forum on East Asia, BKK, June 2012)

Health Measures (official): Children


Singapore
IMR U5MR
% children underweight

Thailand 11 13 7

Burma 50 66 23

2 3 8
(2008)

(2006-2010)

Source: UNICEF. Figures are for 2010.

Basic reproductive health indicators: Moms


Singapore Maternal mortality ratio (per 100K LB) Births attended by skilled personnel At least 1 antenatal visit Unmet need for family planning 3 Thailand 48 Burma 200

100 (1998)

99.5 (2009)

63.9 (2007)

---

99.1 (2009) 3.1% (2006)

79.8 (2007) 19.1% (2001)

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%

Source: National Health Accounts, WHO. All figures from 2010

IT DOES NOT COST A LOT TO SAVE THE LIVES OF MOST MOTHERS AND CHILDREN

Vaccine-preventable diseases
2011 2010 2009 2008 2007

Source: World Health Organization, Immunization Profile: Myanmar http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofil eselect.cfm

Top Health Problems


Thailand:
Cancer (especially liver) Accidents Diabetes Cardiovascular Disease HIV/AIDS

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

The (structural) context

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

Source: TBBC, Oct 2012

International humanitarian assistance blocked

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: clearing roads, Papun District, November 2007.


Source: 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

By community organizations delivering primary health programs


Esp ethnic communities of E Burma: intl humanitarian aid blocked by SPDC Target ~376,000 people, otherwise no access social services

Survey: Sampling frame >325,000 Randomly sampled 5,754 households (27,802 people) Covered 21 rural townships Builds upon previous surveys

Mortality figures, Eastern Burma


Diagnosis Critical, 2010
Burma national Maternal mortality ratio Under 5 mortality rate Infant mortality rate 240 Eastern Burma 721 Sudan

750

71

138

108

54

73

69

MMR WHO 2008 IMR UNICEF 2009

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%

1/14 women had malaria during survey.


Pregnancy + malaria often deadly

41.2% children acutely malnourished


Malaria prevalence amongst women

Risk of pregnancy-related death (2004)


Lifetime Risk of Maternal Death ( 1 in xx ) IDPs of eastern Burma Burma national rate (UNICEF) Thailand U.S.A. Congo Somalia Rwanda 12 75 900 2,500 13 10 10

MOM Project
Mobile Obstetric Maternal Health Worker Network, ethnic, community RH workers Sampled almost 3000 IDPs, 2006

MOM Project, 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%

3.4% IDP women delivered in Burmese, Thai hospital; 7.4% Pf malaria


Sources: Millennium Development Goals Indicators, http://mdgs.un.org, WHO, World Health Statistics 2009; Mullany et al, Access to Esssential Maternal Health interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma, PLoS December 2008.

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%

3.4% IDP women delivered in Burmese, Thai hospital; 7.4% Pf malaria


Sources: Millennium Development Goals Indicators, http://mdgs.un.org, WHO, World Health Statistics 2009; Mullany et al, Access to Esssential Maternal Health interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma, PLoS December 2008.

Population measures. Human Rights Violations:


30.6%: one or more violations in the preceding 12 months (DC, 2010)
Food insecurity: 11.7% Forced cultivation Jatropha 9.5% Forced labor: 8.7% Forced displacement: 5.6% Death by direct violence rare: GSW- 1.7%

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

Associations: HRVs, health (DC, 2010)


Violation Any Prevalence (12 months) 30.6% Outcome Infant death Child death Severe acute childhood malnutrition Forced Labor 8.7% Infant death Child death Increased Odds 1.5 1.4 1.9

2.5 1.9

Associations: HRVs, health (DC, 2010)


Violation
Forced displacement

Prevalence (12 months)


5.6%

Outcome
Child death No contraception Mod-severe acute childhood malnutrition

Increased Odds
1.7 9.1 3.3

Food insecurity

11.7%

Mod-severe acute childhood malnutrition Severe childhood malnutrition

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)

Food Insecurity [BPHWT]: Outcome


Overall mortality Child malnutrition Malaria

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

Most deaths preventable


Malaria, diarrhea, respiratory infections, malnutrition

HR abuses by regime against civilians widespread Closely linked to mortality and morbidity
Malaria analogy: must address root causes

3700+ villages, how many more?

Understanding the (structural) Context: disease case studies

2. The borders are even worse

Homes destroyed in July 23-24th Tatmadaw attack on Tha Dah Der village. [Photo: KHRG]

Case Study: Malaria

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

Source: WHO, SEAR. Malaria: Disease Burden in SEA Region

Source: WHO, SEAR. Malaria: Disease Burden in SEA Region

Malaria in Burma (official)


18% cases but % deaths closest to Indonesia (10%), India (65%) Reported cases (25-40% of all cases?), likely far more deaths

Source: WHO, SEAR. Malaria: Disease Burden in SEA Region

Malaria in Burma (official)


Malaria: Disease Burden in SEA Region

GMS: Burma cases, deaths

Source: WHO, SEAR.

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

KDHW Malaria Program Data


Year Population # Health Workers # VHWs Ratio of all HW: Pop # malaria treatments 2003 1,820 4 0 1:455 278 2007 2010 2011 33,810 48,334 52,342 41 51 1:368 5,041 68 241 1:162 70 285 1:113

12,696 15,906

Health information collaboration: Malaria (underdiagnosis/reporting)


2003: 27,000 cases in Karen State by KDHW, BP. Lao PDR
SPDC: 2,046

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

Top Ten Provinces with highest malaria cases, 2009


N 3.Mae Hong Son (1,567) 3

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.

The Lancet, April 2012

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

Indirect threat: economic impact


2009, 5 border hospitals Tak: 115.6 million baht Umphang, Tak: 20 million Sangklaburi: >8 million Mae Sot Hospital: 40 million baht charity care 2007, 50 M 2008, medical crisis Jan 10: NHSO requests 472 M baht for stateless, esp for infectious diseases
could pass to Thaisif they were not properly controlled

Diseases: symptoms of a deeper illness: threats, span borders

Mae Tao Clinic Annual Report, 2011

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

Outbreak on the border


April 2008: mystery illness in Karen IDPs: cough, fever, rash Samples by KDHW, confirm in BKK: measles Vaccination campaigns of 87.1% at risk (7700 children) Sept 2008: controlled; 512 ill, 4 died

Burmese govt expenditure on childhood vaccines: $0


Official: 87% coverage measles vaccine (estimate) Most vaccines from UNICEF

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

Along Thai border

Menglian County, Yunnan Province

Oct-Nov 09, measles outbreak, Menglian Cty, Yunnan


Start: 14 from Myanmar with fever, rash Then to Menglian popl; 16 cases when abated, Dec 20th

Samples, Yunnan CDC: no match with widely recognized genotypes


Closest link: strain imported from Myanmar to Australia 01 The Menglian viruses responsible for the measles outbreak in China represent strains that are probably associated with endemic transmission of virus in Myanmar.

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

2010 2009 2008 2007 2000 1990 1980

Source: World Health Organization, Immunization Profile: Myanmar http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofil eselect.cfm

2007-2010: Polio-free Dec 2010: 7 month baby, Mandalay


Catch-up vaccination, 3.4M children: many inaccessible communities $$: It is more foreign aid than local funds going to pay for campaigns like the polio eradication effort. (Anonymous physician, RGN, April 2011)

Vaccine-preventable diseases
2011 2010 2009 2008 2007

Source: World Health Organization, Immunization Profile: Myanmar http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofil eselect.cfm

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

Source: WHO, Cholera Global Surveillance Summary, 2008

Who is to blame?

Emerging Threats: Pandemic Influenza Avian Flu (H5N1), Swine Flu (H1N1)

Emerging Threats: Avian Flu


Spanish Flu, 1918

Putting the pieces together


(bad health does not just happen!)

2004: young Shan migrant worker with leg pain, swelling, fever Chiang Mai city Presents to clinic
Concern for malaria blood smear

Wuchereria bancrofti First time in decades

Lymphatic filariasis
Parasite Over 120 million worldwide infected Major cause of disfigurement and disability; severe psychosocial and economic impacts Deaths: secondary infections

Parasite life cycle

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

Severe lymphedema: elephantiasis

Clinical Lymphatic Filariasis

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)

Thailand & Filariasis


Lymphatic Filariasis Prevalence Rate in Thailand, 1992-1999

12 10 8 6 4 2 0
92 19

Prevalence Rate, per 100,000

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

- Thai budget: ~20 million baht ($500,000)

- 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)

LF Nonendemic (19Districts; 12.9m)

Ongoing survey areas ( 1Districts; 1.9m)

MDA areas; 14 Distts; 11m Pop.

- Endemicity map, LF in Thailand:


- Tak - Mae Hong Son - Kanchanaburi

- 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.

2004: 2 symptomatic cases, so what?


Iceberg Phenomenon: Most people with filariasis are ASYMPTOMATIC 2 cases is an epidemic!
There is (are) failures somewhere Not recognizing context can worsen failure

Systematic failures Mongnai


Filariasis Endemic Areas and Areas Under Mass Drug Administration, 2006
11/239
LF Endemic (45 Districts; 40m)

4.6%
338/865

39%
LF Nonendemic (19Districts; 12.9m)

BPHWT & GHAP, APHA November 2010

Ongoing survey areas ( 1Districts; 1.9m)

MDA areas; 14 Distts; 11m Pop.

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)

Burmas current output: ~845 MW


Projected Flood Zone of Tasang Reservoir; from: Roots and Resilience, SAPAWA

PH impact?
130 km from Chiang Mai

Unrevealed costs Abuses in Shan State migration


>400,000 Shans in Thailand? (SWAN)

Thai involvement ? Just one example of displacement (abuse) by development

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.

5. The root causes (multifactorial) need to be urgently addressed


(Messy: the basic problem is NOT simply poverty, conflict, humanitarian disasters)

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%

$79.8 $15 5.9%

$50.5 $17 10.5%

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

Natural gas sales to Thailand 2010: $4 billion

$16 billion in last decade (2012)


Opaque, abuse, land confiscation Open to US investment

More from minerals

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)

Good Buddhists ???!

The heavy weight

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)

5. The root causes need to be urgently addressed


The most cost-effective health intervention may not be biomedical; may be structural: Respecting human rights, environment, rights or women, children, vulnerable populations; addressing poverty, migration, inequity

GOOD GOVERNANCE
(Durable public health change remains distant)

Budget, February 2012-13


Military: 14.4%, $2.3B (incr 60%)
More: military conglomerates (UMEC), black budget, Special Funds Law

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.

Burmas past, present, future


Ceasefires signed with 12 armed groups since Sept 2011
Verbal (informal) agreements An elusive peace?

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

BGF = clashes Jun 11; end 1994 ceasefire with KIO


Development: 2 Chinese hydropower dams, gas pipeline (resented locally)

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

Rule of Law? Impunity for abuse continues


All townships Chin State (White Zone) 92% HH experienced forced labor in 1 yr 15% torture/beating 3% rape/sexual violence >50%: Livestock stolen, forced to give food Almost entirely by SPDC Curtailed international access, poverty, famine disaster
India: >75,000 Malaysia: >50,000

National Human Rights Commission


Presidential decree Sept 11 that there are no indications as yet that the Commission is fully independent... it seems that the Commission cannot fully guarantee human rights protection for all in Myanmar. (T Quintana, UN, Feb 12) [For NHRC] to investigate [abuses] into conflict areas would not be appropriate at this time. (Win Mra, chair, Feb 12) The government has utterly failed to rein in the army serious human rights abuses continue throughout the country, with little accountability for those committing these crimes, (ITUC, Mar 12) Reports of widespread, systematic abuses against civilians one-sided; Our military is very disciplined, there is no reason for the military to commit acts of rape or murder. (Thein Sein, BBC, Sept 12)

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)

Links to poor health outcomes

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.

Development: Tavoy (Dawei) (it gets worse)

ASEAN connectivity: Tavoy (Dawei)

Deep sea port & industrial estate


Italian-Thai Development 2018

Road ($1B), port ($2B)


Bypass Strait of Malacca Steel mills, oil refineries, power plants, paper plant, petrochemicals, fertilizers
NIMBY

~$80B, 200-250 sq km zone


>10X larger Thai industrial estates May displace >30,000

Many other examples Social, economic, health impact ???

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?

Sittwe mostly empty of Muslims; Muslims in camps: new Apartheid.


Malnutrition, malaria, other health problems Aid blocked, limited: That we are prevented from
acting and threatened for wanting to deliver medical aid to those in need is shocking and leaves tens of thousands without the medical care they urgently need. (Joe Belliveau, DWB, Nov 12)
Ive never experienced this degree of intoleranceOur own staff are simply scared and unwilling to work after receiving direct threats.

Addressing the root causes


It [Burmas humanitarian crisis] arises from politics, from a war waged by the regime against the society, a war aimed at destroying the human capital of the country and society.

Chao Tzang Yawnghwe (Eugene Thaike) 1939-2004

Which way will Burma go?


Harn Lay, June 2012

Healthy skepticism
(Member of Parliament DASSK, BKK, June 2012)

Tangible structural change? (Sanctions & Development)

Very Important Slide (1)!


Basic Health is a human right!
Universal Declaration of Human Rights (1948), Article 25: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services motherhood and childhood are entitled to special care and assistance WHO Constitution: the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being International Covenant on Economic, Social and Cultural Rights (1976), Article 12: The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health

Very Important Slide (2)!


Why do we get sick?
Germs; bad health does not just happen Often closely linked, multi-factorial: other human rights, migration, economics, environment, discrimination, womens rights, child rights Poor health is a FAILURE: can indicate lack of rights, especially for the most vulnerable

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

Beyond Burma: Rubiks Cube of Health


Health is one face of multidimensional problem: must understand (structural) context for durable solutions
poverty, environment, governance, migration, rights

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

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