This Report is dedicated to the memory of those who lost their lives in the service of Back Pack Health Worker Team. We off er our gra tude to these 10 brave and commi ed individuals and send our prayers to their loved ones. On a daily basis, BPHWTs traverse areas of ac ve confl ict and territories where the landscape is li ered with land mines. Traveling from village to village, BPHWT members must trek, climb, nego ate river waters and determine if there is a safe means to evade a confl ict situa on and reach the villages that await their skilled care. These health workers consistently put the welfare of their communi es above their own personal safety. As a result of their selfl ess service, countless villagers have enjoyed improved health and enhanced understanding. May their memories live on in our hearts and be a blessing to every BPHWT member and to all those we serve everyday.

Maran Seng Ra 2018

Saw San Thein 2015

Khaing Soe Paing 2015

Zi Wah Ni 2009

Saw Eh Keh 2004

Saw Ta Pi 2003

Saw Maung Myint 2002

Ka Haw Moo 2001

Tu Naing 2000

Saw Nay Say 2000

i The Back Pack Health Worker Team extends our hear elt apprecia on to the generous donors and partners which have sustained our work for 20 years. In addi on to these organiza ons, countless individual contributors have supported us. Thank you, without you this life-saving work would not be possible!

Burma Humanitarian Mission Burma Refugee Care Project Burma Relief Centre Canadian Interna onal Development Agency Chris an Aid Commi ee for Protec on and Promo on of Child Rights Community Partners Interna onal Crossroads Charity Danish Church Aid Department for Interna onal Development (UK) Global Aff airs Canada Global Health Access Program Help without Fron ers Interna onal Rescue Commi ee Interna onal Commi ee of the Red Cross Inter Pares Johns Hopkins University Just Aid Founda on Karen Department of Health and Welfare Mae Tao Clinic Mainly I Love Kids Marie Stopes Interna onal-Myanmar Mitwelt Netzwerk Norwegian Church Aid Not On Our Watch Open Society Founda on Open Society Ins tute People in Need Rotary Club of Sebastopol Sunrise, CA USA Rotary Thailand Shoklo Malaria Research Unit S ch ng Revalida e Medisch Groot Klimmendaal S ch ng Vluchteling Swiss Agency for Development and Coopera on Terre des Hommes The Border Consor um United States Agency for Interna onal Development University Research Co., LLC Voluntary Service Overseas Women’s Educa on for Advancement and Empowerment World Children’s Prize

~ Our sincere apologies for any omissions ~ ii Table of Contents

Dedica on ...... i Donor Apprecia on ...... ii Forward by Dr. Cynthia Maung ...... 2 Introduc on by Saw Win Kyaw ...... 3 Brief History of Burma ...... 5 Health Care in Burma ...... 13 Back Pack Health Worker Team's Founders, Vision, Mission & Goal ...... 17 Health Care for IDPs and Vulnerable People in Burma ...... 19 Understanding the Popula on Data ...... 22 Map of BPHWT Service Areas ...... 23 Birth of the Back Pack Health Worker Team ...... 25 New & Noteworthy: 1998-2017 Program Highlights, Lessons Learned, New Challenges to Address ...... 29 Tes monials From BPHWT’s Field Areas ...... 49 Three Sustaining Programs, Three Major Illnesses ...... 53 Human Resources and Capacity Building Program ...... 59 Building Coali ons for Las ng Change ...... 63 Fulfi lling Our Promise: BPHWT Looks Toward the Future ...... 69 Notes ...... 77 Source Materials...... 78

All pictures throughout this Report are of BPHWT health workers except where noted

1 FORWARD Dr. Cynthia Maung Chairperson, Leading CommiƩ ee, Back Pack Health Worker Team

My awareness of the stark disparity in access to health care in Burma began during medical school. An internship at two general hospitals plunged me into a system that was under- resourced and under-staff ed. A en on was necessarily devoted to addressing serious problems; there was neither me nor resources to off er preventa ve or basic primary health care. A er the uprising of August 8, 1988, as I made my way across the country toward Thailand, I met many people in rural and remote areas of Burma. These people were in desperate need of health care; they had never had access to even rudimentary medical services. In Thailand, students and doctors who had fl ed the country began pooling resources and discussing how we could best bring primary and confl ict-related health care to Burma’s remote communi es. We began sending small teams of medics into Burma; each person ou i ed with a backpack of medicines and supplies and each team traveling to a circuit of villages for several months at a me. In 1997 – 1998 pervasive and hard-hi ng a acks by the Burma military on many ethnic communi es in Eastern Burma caused internal displacement, increased numbers of refugees and the destruc on of ethnic health and educa on infrastructures. Health workers from various groups met to discuss how to rebuild and support vulnerable people and communi es. From this came the Back Pack Health Worker Team (BPHWT) in 1998. Burma as a na on has undergone much change since that me. The Na onwide Ceasefi re Agreement, has been met with varying degrees of sincerity and insult, ins lling the minority ethnic popula on alternately with hope, suspicion and cau on. With the Na onal Health Plan, and its concomitant goal of Universal Health Care by 2030, the Ministry of Health and Sports has at last acknowledged the serious fi ssure in healthcare access within the na on. Through it all, the BPHWT has remained both responsive to and ac ve in shaping policy and prac ce that eff ects health care for Burma’s ethnic minori es. The BPHWT not only brings health care to the communi es we serve, but empowers communi es and individuals to be er care for themselves. The BPHWT has created a network of Community Health Workers (456 workers in 2017) and Village Health Commi ees (44 commi ees, with 455 leaders in 2017) that provide consistent on-going care and par cipatory guidance in their villages. The BPHWT provides training to hundreds of Tradi onal Birth A endants / Trained Tradi onal Birth A endants (799 in 2017) who play a vital role in promo ng maternal and child health while crea ng a cri cal link between villagers and the larger ethnic health system. The BPHWT is forging rela onships with other organiza ons, socie es and governments; the BPHWT is an important member of the Ethnic Health Systems Strengthening Group, the Health Informa on Systems Working Group, and the Health Convergence Core Group. Together we are working to lead systemwide change in health care, develop robust and systemwide demonstrable data that can be shared and used to determine programs and policy going forward, and assure that ethnic health workers receive accredita on and acknowledgment so that their roles are enshrined in Burma’s future. This document celebrates the BPHWT’s 20 years of growth and change. Our experience has made us stronger. Our partner organiza ons have broadened our horizons. Our funders have made it possible to deepen knowledge with training, deliver context- appropriate care, and provide needed medicines and supplies to hundreds of thousands of people. We off er our hear elt thanks to all who have played a part in this life-saving work.

2 INTRODUCTION Saw Win Kyaw Director, ExecuƟ ve Board, Back Pack Health Worker Team

Over 20 years, the Back Pack Health Worker Team (BPHWT) has grown to embrace a wide range of health workers and reached ever further to address the healthcare needs of remote ethnic popula ons. We have increased and changed program off erings, remaining responsive to emergent and shi ing in needs in the communi es we support as well as keeping abreast of interna onal standards, protocols, tes ng and treatment within our areas of care. The BPHWT has signifi cantly improved wellness and brought knowledge and the tools of self-care to hundreds of thousands. With an ini al target popula on of 45,000 in 1998, we now serve nearly 300,000 (2017). We began with 32 teams and 120 health workers in 2018; our teams now number 114, with 456 health workers. We currently reach every state and 3 regions in Burma. Due to rela ve stability in some areas, 48 of our teams are “sta onary teams” where a dedicated building enables storage of medicines and basic supplies, and a space for examina on and consulta on areas. Villagers come to the building when in need of care; workers s ll travel to villagers’ homes as needed. We also train Village Health Workers and Trained Tradi onal Birth A endants who live full- me in their communi es and off er on-going care and immediate medical response. This supports our mission of empowering communi es with the skills and knowledge that will enable greater self-care. The BPHWT has 3 main programs: Medical Care Program (MCP), Maternal and Child Healthcare Program (MCHP) and Community Health, Educa on and Preven on Program (CHEPP). All MCP’s frequently-seen major illnesses have been markedly reduced in the past two decades. In the past 10 years, cases of malaria have decreased by 89% in our target popula on — a result not only of more accurate tes ng, early interven on and medicines, but also signifi cant a tude change regarding use of mosquito nets and water/ sanita on prac ces. We learned early on that primary health care cannot be divorced from clean water, sanita on and hygiene and developed a mul -faceted program to bring workshops and educa onal off erings to the communi es we visit (CHEPP). The MCHP is a vital component of our work: in 2017, 4144 babies were born in our target areas — more than ever before! Well-trained health workers, prepared mothers, and a en on to sanitary environments have borne real results: while 135 s llbirths were recorded in 2002 (6% of all births), in 2017 there were only 29 (0.007% of all births). Some things are beyond our ability to control —injuries due to landmines, gunshot, and other casual es of war are an on-going legacy for too many living in Burma. The risks of malnutri on, exposure, and disease are infi nitely greater to displaced popula ons than stable communi es. The risks to health due to unscrupulous development, resource extrac on and natural- and human-made disasters will persist. The BPHWT will con nue to provide care and emergency assistance to those who are aff ected. For 20 years, we have faced repeated challenges to the delivery of health care. Even as obstacles and threats con nue, we will persevere. Our role remains as vital as ever: We will con nue to strive for quality accessible, low- or no-cost health care to all ethnic people in a Federal Union of Burma. Not only do we provide care, we are the recipients of care, and we are driving the policy and network that will support health care in Burma for decades to come. We extend our apprecia on to all health workers, staff , partner organiza ons, donors, volunteers and anyone who has ever contributed to the BPHWT. We look forward to the next 20 years of change and improved health!

3 4 Brief History of Burma

Economic Displacement and Human Rights Abuses of Burma’s Ethnic Peoples

In 2012 President Thein Sein li ed economic sanc ons and opened the door to foreign investors and development. As the military government priori zed business interests over inclusion of and meaningful dialogue with all Burma’s people, foreign and state-sanc oned companies poured into Burma seeking to exploit resource- rich lands for development. Some villages were to forced to relocate, others were forced into service, most without compensa on. Natural resource extrac ve projects have not only led to the taking of ethnic minority lands, but the pollu ng of cri cal resources leading to a range of illnesses.

In the Ta’ang/Palaung ethnic area of Northern Shan State, the community has been devastated by the eff ects of the Shwe Gas and Oil Pipeline, a joint venture of the China Na onal Petroleum Company (CNPC) and the Myanmar Oil and Gas Enterprise (MOGE). This project will bring crude oil and natural gas from Arakan State, through Central Burma and Northern Shan State to China’s Yunnan Province. As a result of this large-scale energy project, the pipeline running through the Ta’ang/Palaung area has led to increased deployment of Burma Army troops in each village on the route. The Burma Army has been confi sca ng land, pos ng armed guards at pipeline sites, and providing a military security detail to Chinese workers. Back Pack health workers reported that increased militariza on in this area has led to neardaily fi gh ng between the Burma Army and ethnic armies, displacement of villagers, escala on of human rights abuses, increased drug trade and abuse, increased pros tu on and violence against women, restricted access to health care, land confi sca on, and environmental degrada on. The Burma Army soldiers are not the only perpetrators of human rights viola ons – Chinese men working on the pipeline are guilty of crimes against the local popula on. In October 2012, a thirteen year-old girl walking home from school in Namkham Township died a er being abducted and gang-raped by ten Chinese workers from the CNPC. - Adapted from the BPHWT 2012 Annual Report

A country’s history is fundamental to data, both from offi cial internal sources the crea on of its iden ty; a na onal and reputable interna onal actors, has history forges a na onal iden ty. Yet been skewed toward the majority group Burma’s “na onal iden ty” has omi ed and excluded large segments of Burma’s the lives of many of its people. Burma’s ethnic popula on. This has resulted in an history is complex and o en confusing: unbalanced na onal iden ty story with an allegiances have changed and terms of implicit lack of a simultaneous, confl ic ng agreement and ceasefi re have repeatedly narra ve. Percep ons beyond Burma’s been brokered and broken. Reported borders have been biased by an absence

5 the central plains. Many ethnic minori es live in the borderlands of Burma and large numbers, due to military incursions and state-supported development, have become Internally Displaced Persons (IDPs) within their own country or refugees in neighboring countries having fl ed violence and human rights viola ons at home. These ethnic groups include Shan, 9% of Burma’s popula on; Karen 7%; Arakanese 4%; and Mon 2%; other groups include Karenni, Chin, A village in Burma’s hills Kachin; and a mul tude of ethnic groups of ques oning the dominant ethnocentric paradigm. For these reasons it is important to devote some space here to Burma’s tumultuous history.

Burma has been living with extreme unrest for decades. Before and since independence from Britain in 1948, the country of approximately 54 million people has been under the constant yolk of armed violence and human rights abuses and corresponding Back Pack health worker delivers health care resistance and struggle. The CIA World to all, irrespec ve of religion, ethnic group Factbook (2014) helps draw the picture of or poli cal beliefs a na on of ethnic groups. The largest of these groups, the Bamar or Burmans (for which the country was named) cons tute that are smaller in overall popula on. The 68% of the popula on and lives largely in Burmese Na onality Law, 1982, recognizes 135 dis nct ethnic minori es within Burma — although this is both contested and controversial.

Before the Bri sh colony was established in 1886, Burma was a united yet separate group of territories within one border. Under Bri sh rule, a system of segrega on and hierarchy was established where none previously existed. Bri sh administra on divided the territories into Burma Proper and the Fron er Lands. Burma Proper, in the central plains area, was home to the A knee wound receives medical care from a Burman ethnic majority; the Fron er Lands Back Pack health worker 6 ethnic groups. Notably absent from the historic Panglong Conference convened in February 1947 to dra the country’s new Cons tu on were Karenni, Arakanese, Mon and numerous other ethnic group leaders. Among the ethnic groups present, many did not have the right to par cipate on a par with the Burmans. As a result, even in its infancy, the rights accorded to minority It can take hours or days to reach a village to ethnic people in the new Union of Burma bring medical care and educa on were at best ambiguous and at worst completely absent.

defi ned the border areas where other The assassina on of General Aung San (and ethnic groups lived. These two areas were the majority of his cabinet ministers) fi ve governed separately: while the new leaders months a er Panglong, prior to further provided administra on and support nego a ons on unifi ca on and before the for Burma Proper, the ethnic groups country’s independence was offi cial, le were accorded self-rule in their regions. many issues between the former Burma This approach of dividing the country Proper and the Fron er Lands unresolved. into regions with separate policies and A colleague of Aung San, U Nu assumed treatment for diff erent areas was to have the reins as prime minister and ushered far-reaching consequences in both a tude in an “independent” Burma. However, and in policy for decades to come. unresolved issues and consistently violated rights led to an on-going climate of mistrust With a fought-for and nego ated and violence between the na onal Burma independence, the country set its hopes Military and the ethnic opposi on armies upon General Aung San in nego a ng a that persists to this day. way forward in the new “united” country. However, the mechanisms for unifi ca on In 1962 a military coup ended the of the new Union were not nego ated Parlimentary Democracy and established a with full par cipa on of or buy-in by all one-party system with General Ne Win as leader. For the next 14 years, ethnic voices were suppressed and Burma was ruled brutally as a ma er of course. One spoke out against the regime at risk of harm or death. S ll, students braved protest repeatedly (in 1965, 1969, 1970 and 1974). On August 8, 1988 in a demonstra on led by students and joined by monks, children, and ci zens, hundreds of thousands of protestors took to the streets in Rangoon demanding change: an end to the military regime and a democra cally-elected Back Pack health workers s tch up a hand government. This became known as the wound 8888 na onwide popular pro-democracy

7 on the possibility of the NLD overthrowing the oppressive regime and leading the country to the freedoms it had long sought. Due in part to her growing popularity, the SLORC placed Suu Kyi under house arrest some 10 months later.

At the same me, the SLORC ini ated a brutal crackdown, arres ng and killing thousands including students, civilians and leaders of the newly-established NLD. S ll, Family members look on as blood pressure elec ons in 1990 saw the NLD winning 392 is checked seats in the Union Parliament to SLORC’s 10 seats. The military regime refused to acknowledge the results of the elec on as uprising. The military responded by gassing, legi mate and maintained power. Many of killing, and imprisoning protestors; others those who had been elected were arrested fl ed Burma to further organize from a place where their lives were not under constant threat.

The protest forced Ne Win to step down. A er a replacement who held but a month- long tenure, a military coup seated a new government: the State Law and Order Restora on Council (SLORC). In the midst of this poli cal upheaval, the daughter of slain General Aung San, Daw Aung San Suu Kyi, returned to Burma. Her leading voice for a democra cally-elected government led to the founding of the Na onal League for An infected wound causes swelling and pain Democracy (NLD). People hung their hopes to this li le girl

while others fl ed into areas controlled by Ethnic Armed Organiza ons (EAOs).

Heavy fi gh ng con nued for the next four years. During this me SLORC off ered ceasefi re agreements to certain EAOs — o en such agreements were padded with favors, business/fi nancial opportuni es or other privileges to encourage members of an EAO to break with their army and Burma is a beau ful country with vast join the Burma military. Another tac c natural resources the SLORC employed was to approach 8 by ac vists, students and local ci zens. The peaceful “Saff ron Revolu on” (so named for the monk’s saff ron robes) demanded poli cal representa on and economic jus ce. The SPDC response was immediate and brutal; many were killed and arrested.

In the wake of massively destruc ve Cyclone Nargis the following year, the military barred interna onal aid from reaching hundreds of thousands who desperately Back Pack health worker trea ng pa ent needed it. And, though much of the with burns country was in disaster recovery mode, a cons tu onal referendum vote scheduled for only days a er the cyclone hit, went one fac on of an ethnic army and seek to ahead. Under threat of harm, ci zens voted recruit its members, thus weakening the overwhelmingly for the oppressive 2008 mother organiza on. Contrary to its intent, Cons tu on. The role of Burma’s military as this fac onaliza on o en led to increased fi gh ng and the need for mul ple addi onal ceasefi re agreements.

The SLORC refashioned its image along with its name in 1997 and became the State Peace and Development Council (SPDC). An economically repressive environment exacerbated by a sudden and excessive hike in fuel, food and other commodity prices led to massive protests again in It takes several people to safely refer a pa ent 2007. Countrywide, thousands of monks protested in the streets and were joined stated in the 2008 Cons tu on cannot be overstated; it is central in all aff airs of state. The Cons tu on simultaneously assures the role of the military and a centralized government.

The 2015 elec on saw 70% of Burma’s 34.5 million eligible voters cas ng ballots for the House of Na onali es and the House of Representa ves. Aung San Suu Kyi was seated as the State Counsellor, a tle and posi on fashioned specifi cally for her. Notwithstanding the elec on of a Back Pack health worker carefully close colleague, U H n Kyaw, as President administers an injec on

9 interna onal community and “the face of Burma “ the world over, Aung San Suu Kyi’s role and that of the NLD is both complex and diffi cult. The might of the military arm of the government and its ability to veto any eff orts for genuine democra c change cannot be ignored. Military a acks, land seizures and human rights abuses have con nued unabated. With the NCA, ethnic equality and autonomy remain unresolved issues and although the ceasefi re and Taking vital signs includes a blood pressure peace process has progressed, its lack of check inclusivity and specifi city, its lack of any statement concerning the code of military conduct or provisions for independent in March 2016 (resigned and replaced in March 2018), Aung San Suu Kyi remains the defacto leader of the country.

With the elec on of Aung San Suu Kyi and her party, the NLD, hopes were high and new eff orts afoot for a Na onwide Ceasefi re Agreement (NCA). The NCA ini ally received 8 and now has 10 signatories; it has been repeatedly violated by the Burma military in order to achieve tac cal or strategic objec ves or to expand or strengthen its posi ons. Ausculta on for lung sounds Although long beloved by many of her country people, revered by the monitoring and the military’s blatant and consistent disregard for honoring the territorial impera ve of current signatories are troubling.

At the close of 2016 the Internal Displacement Monitoring Center (IDMC) indicated there were 1,153,000 internally displaced persons in Burma due to confl ict, violence and disasters; 544,000 added in 2016 alone. Addi onally, the IDMC documented 490,000 refugees in 2016. 2017 fared no be er, the fi rst six months of the year having 23,600 people displaced A growth in the eye will need care from due to confl ict, violence and disasters; and specialist the later half of the year invi ng worldwide 10 A pregnant women is examined as she rests Elderly man discusses his care while his with her two children daughter and grandson listen horror as the crisis in Arakan State unfolded its painful history is one of marginaliza on and worsened. This me roughly 700,000 and human rights viola ons. The path Rohingya were exiled as refugees in towards peace, democracy and a truly Bangladesh with thousands more internally inclusive Burma will require massive change displaced. and genuine commitment. Eff orts are afoot on mul ple fronts in this many-year long The road forward is one of great challenge. process. This complex environment is the Burma is a land of great riches — from its framework for BPHWT’s bold and life- ethnic diversity to its natural resources. Yet saving work.

11 12 Health Care in Burma

Burma is ailing. It suff ers from decades of health care in Burma. According to the neglect — a lack of investment in the health World Bank, in 2012 more than 93% of of its people and a systemic caste system healthcare costs in Burma were paid for where availability of state-sponsored health privately — including basic primary and care is largely limited to the populace and preventa ve health care. While there has majority-culture areas, by-passing the rural, been improvement, this rate lowered to remote and displaced ethnic minori es. 81% in 2014, and to 54% in 2015, ci zens in Burma’s people are literally being kept Burma carry a far greater payment burden hungry, sick and red. than the global average of 32% of costs paid privately, and the NLD’s own goal of Ranking 188 on a list of 192 countries in 25% (by 2020). The delivery of care is so terms of na onal GDP spent on healthcare, defi cient that even among those who have Burma dedicates only 2.3% of its GDP to the means to pay, many seek medical care the health of its people (a change of only elsewhere. Medical tourism out of Burma +.1% in 20 years). By comparison, the is on the rise. In Malaysia alone there United States of America dedicates 17.1%, was a 23% increase from 2011 to 2012 in Germany 11.2%, and Serbia 10.4%; only Burmese seeking health care (3,4). Amongst Qatar, Turkmenistan, Laos and Timor-Leste the poor and persecuted ethnic minori es, dedicate fewer funds.(1) From a rate of just this problem is compounded – there is both below $3 per capita for health care in 2000, a lack of resources locally and an inability Burma now allocates $59 per capita for to pay for services at an urban center. health care, while it’s neighbor Thailand Burma has yet to address the striking allots $217 per capita, China $426, and the disparity of care available in urban and USA $9,536 (2). rural popula ons, and between the ethnic minori es and the majority Burmans. This lack of investment in the health of Burma’s people is refl ected in large out- A further challenge to eff ec ve and of-pocket costs borne by those who access appropriate disbursal of allocated funds remains the absence of a credible administra ve body to oversee fund expenditure, thus rendering the advantage of an increase in available funds ques onable. Nor is there any priori zed, publicly available record of fund recipients or regions. It is impossible to follow allocated funds to ensure they reach the intended target: for a government that has been plagued with corrup on, these are serious accountability concerns.

Investment in the training and deployment of medical professionals has been similarly Debriding the skin lacking. According to a 2014 Ministry of

13 Life-saving Referral and the Challenges of Rainy Season We had one case with a pregnant woman. She had pre-eclampsia and was a high- risk pregnancy. We no ced a change in her blood pressure, a lot of edema and she became hypertensive. We needed to refer her to hospital. But it was rainy season and we are in a very mountainous area. Transfer was very diffi cult, it took three days. She got to the hospital and they did a cesarean sec on. The baby died but the woman was okay. If we had not referred her to hospital when we did, the mother might have died, too. -Lway Poe Khaung, Palaung Field in-Charge

Health report, there were at that me 15 quality educa on. Under separate budgets, universi es off ering medical courses to the Ministries of Defense, Railways, Mines, nearly 1,200 students in medical, dental, Industry, Energy, Home and Transport each pharmacy, medical technology, and provide health care for employees and community health areas of specializa on. their families within their own facili es. A There is no private medical university countrywide survey in 2013-2014 revealed in Burma; the Ministry of Health and a total of 13,099 doctors in the country, an Sports, the Ministry of Educa on, and the 11.7% increase from 2011-2012 (5). Ministry of Defense are responsible for the training of the health workforce. Although Who are these future doctors and medical the availability doctors, 61 per 100,000 professionals? Burma’s medical students are popula on, is inadequate to meet the need, predominantly drawn from the country’s in 2012 the government reduced those wealthier families and live in major urban accepted for medical training by half and areas. Once doctors, many prefer working extended the study period from six to seven in ci es where transporta on and the years, sta ng that this was needed to ensure most current communica on technology is

Naviga ng the road in rainy season Ge ng supplies to the next BPHWT loca on is a group eff ort! 14 A variety of reasons were cited for the original sanc on from refusal to accept a rural pos ng, to hospital mismanagement and corrup on, to those who fl ed Burma due to the oppressive military regime.

While doctors generally prefer an urban pos ng, roughly 70% of the country’s nearly 54 million people live in rural areas of Burma. S ll, most health services Pa ent referral can be perilous for pa ent con nue to be concentrated in larger and Back Pack health worker towns and ci es. Rural health centers, a third- er health delivery service under the readily accessible. Urban centers are also government’s health structure, saw a 17% home to the country’s private hospitals increase over 24 years (7); during this me, that serve wealthy ci zens and off er top salaries, favorable working condi ons and more modern facili es. Some doctors choose to work outside the country in lieu of serving in the capacity of a rural doctor. In fact, current medical workers describe pay for doctors sent to rural areas of Burma as “not respectable” and “discouraging.” (6)

As a response to the acute need for doctors, the Ministry of Health in 2013 removed 1,010 sanc oned doctors from a Delivering supplies to the next village “blacklist.” The doctors had been stripped of their medical licenses and, if residing in the popula on increased by 12 million. Burma, not permi ed to travel outside the Many of these centers are noted for lack country; those doctors who were outside of medicines and supplies. Staff serve on the country were not permi ed to return. a part- me basis and frequently workers are assigned to communi es where they do not speak the ethnic language, thus hampering eff ec veness and compromising trust. Pa ents with more complex medical needs are required to seek care in a larger city, Rangoon and Mandalay having two predominant specialist hospitals. However since the average Burmese household spends 70% of their income on food alone (8), travel to and the burden of paying exorbitant out-of-pocket costs for health care is a luxury few can aff ord. Dental care is an important aspect of What are these out-of-pocket costs? primary health care Pa ents are customarily expected to pay 15 There are only two dedicated psychiatric hospitals that provide pharmaceu cal- focused treatment for pa ents with major disorders. No counseling services are off ered on an outpa ent basis(11). Since 2013, counseling services have been available through the Thai-based Assistance Associa on for Poli cal Prisoners' (AAPP) Mental Health Assistance Project. Currently the AAPP off ers services in Rangoon, Mandalay and in Mae Sot, Thailand. In line with their mission, these services, developed in collabora on with Johns Hopkins University, are available solely to Novice receives care for an arm injury poli cal prisoners and their families. for medicines, the use of equipment, extra blankets, even in some loca ons, for the use of the toilet. And, incidental to the actual delivery of care, costs may include expected “favors,” the greasing of a palm to ensure quality care. In fact, as much as 82% of healthcare spending is out-of- pocket, the 2nd highest rate in the world (9). Pa ents who are unwilling or unable to pay such bribes report longer wait mes, Teaching how to check for the heartbeat substandard care and, some mes, refusal and movement of the fetus to treat.

Mental health care is in even more dire A hoped for commitment to and improved circumstances. In 2016, the head of funding for health care in Burma is showing psychiatry at Yangon University reported glimmers of hope, yet actual change has that there was one psychiatrist per 260,000 thus far been nominal. At the close of popula on (10). 2016, the health sector was fl ooded with possibility and an cipa on at the recently released, Na onal Health Plan (NHP). The NHP was dra ed in an eff ort to meet the WHO’s mandate for universal health coverage by 2030. Although much remains to be sorted out, the NHP outlines a future where health services are widely available both in urban and rural se ngs, on a fee- appropriate basis, and off ered to minority ethnic communi es on a par with Burma’s ethnic majority. Trea ng a child in IPD at a BPHWT clinic

16 Back Pack Health Worker Team's Founders

Vision ~ The vision of the Back Pack Health Worker Team is that of a healthy society in which accessible and primary health care is provided to all ethnic people in a Federal Union of Burma.

Mission ~ The Back Pack Health Worker Team is a community-based organiza on established by health workers from their respec ve ethnic areas. The BPHWT equips ethnic people, living in rural and remote areas, with the knowledge and skills necessary to manage and address their own health care problems, while working toward the long-term sustainable development of a primary healthcare infrastructure in Burma.

Goal ~ The goal of the BPHWT is to reduce morbidity and mortality and minimize disability by enabling and empowering the community through primary healthcare.

17 BPHWT's Leading Commi ee and Back Pack workers from diff erent ethnic areas

BPHWT's 7th Conference and Annual General mee ng

18 Health Care for IDPs and Vulnerable People in Burma

Healthcare Delivery within the Confl ict Zone Violent confl ict and human rights viola ons both increase the need for health services and create barriers to delivering health care. In addi on to the obvious and signifi cant dangers of working in confl ict areas, Back Pack team experience challenges in reaching target popula ons. Frequent displacement of communi es due to violence and development projects disrupt the con nuity of BPHWT programs and worsen community members’ ability to access health care and medicines. Even in ceasefi re areas, obstruc ons to healthcare delivery persist due increased checkpoints, forced taxa on and bribery. All this is added to already diffi cult access due to natural physical barriers, par cularly during rainy season. - Adapted from the BPHWT 2012 Annual Report

The United Na ons High Commission on While the health situa on in Burma is Refugees (UNHCR) says this of Internally poor, the situa on for Burma’s vulnerable Displaced Persons (IDPs): while IDPs may ethnic and IDP popula on is on even have fl ed their homes for similar reasons more precarious foo ng. Some IDPs are [as refugees], IDPs stay within their own forcibly displaced from their land to make country and remain under the protec on way for industrial or business interests, of its government, even if that government resource extrac on or construc on of is the reason for their displacement. As a military quarters or supply areas; others result, these people are among the most are fl eeing physical harm and other human vulnerable in the world (12) rights abuses. All IDPs and minority ethnic

Displaced families and neighbors hiding Back Pack health workers use available together in the jungle resources to make a bed for a sick IDP

19 Exposure to/spread of preventable disease - increased risk of TB, vector-borne diseases, STIs (including HIV/ AIDS) - illnesses such as diarrhea can easily progress to dehydra on and serious risk to life - diseases resul ng from insuffi cient sanita on and disposal of human excrement Back Pack health worker at an IDP camp - increased acute respiratory infec ons due to unsanitary condi ons, open fi res, exposure Burmese have had their lives radically to extreme temperatures, compromised in the course of 50+ years of inadequate shelter confl ict. - serious illnesses swi ly become fatal illnesses In 2016, the Internal Displacement Monitoring Centre’s global database cited a Disease/Illness due to insuffi cient supply of total of 1,153,000 people displaced in Burma clean drinking water due to confl ict, violence and disasters; and - water-borne illness due to an addi onal 490,000 refugees who le the unsanitary water supply country seeking a new life in one of Burma’s - dehydra on due to insuffi cient border countries (UNHCR). 2017 promises clean water to see a radical spike in these numbers as over 700,000 of Arakan State’s Rohingya Complica ons in pregnancy/childbirth and people have fl ed the country in the fi nal lack of basic and obstetric care four months of year alone. Increased propensity to contract malaria There is a unique and dangerous health and dengue fever due to increased exposure profi le for the IDP. Poli cal, environmental, and inadequate shelter economic and socio-cultural determinants of health are adversely infl uenced by condi ons of confl ict and displacement. Harsh living condi ons and the struggle for survival present daily challenges. Exposure to on-going violent confl ict and forced displacement impacts every aspect of physical and mental well-being:

Malnutri on/poor nutri on - due to destruc on of crops, food store or loo ng of food - inadequate food to support all members of family/community IDPs set up camp 20 Health Organiza ons (CBEHOs) are in a Denial of or severely restricted access to posi on to eff ec vely off er support to these health services due to: popula ons. Due to the tenta ve nature - damage or destruc on of health of the Na onwide Ceasefi re Agreement facili es (NCA), it’s many brokered and broken - a acks on or obstruc on to agreements and the lack of trust between healthcare transports (referrals par es, the BPHWT remains a vital player in for more comprehensive care) the on-going health needs of Burma’s IDPs, - in mida on of health providers rural and vulnerable ethnic popula ons. and/or pa ents As the details of both the NCA and the - a acks of health workers and the Na onal Health Plan are worked through, subsequent loo ng or destruc on the possibility exists that health care on of medicines and supplies the village, tract and community level may be enhanced and supported by the Burma Greater risk of injuries specifi cally related government. EHOs and CBEHOs serve a to armed confl ict: vital role both currently and in the future; - increased incidence of landmine the need for the BPHWT is as indispensable injuries/deaths as ever. - increased incidence of gunshot injuries/deaths

Mental health complica ons: - due to physical and emo onal stress, trauma and exer on - due to lack of stability

Children under fi ve, pregnant women and those whose health is already compromised are especially vulnerable to disease and illness under these circumstances. Currently only Ethnic Health Organiza ons Under a ack, villagers leave home to hide in (EHOs) and Community-Based Ethnic the jungle

21 Understanding the PopulaƟ on Data

From 30 March to 10 April 2014, 100,000 listed as one group, and confusion around census takers in Burma undertook the naming of groups and sub-groups. fi rst census in 30 years. The theme of the census, “A Na onwide Census – Let us all Census fi ndings were fi rst published in Par cipate,” was sadly and predictably May 2015 with a subsequent update in unrealized. Contrary to enhancing December 2015. Although some townships understanding of the popula on profi le noted a three-fold popula on increase in of the country, the rush to complete the the update, the December data sported census prior to 2015 elec ons resulted in a caveat that numbers were “subject to a census that has promulgated profound change.” Although results failed to meet inaccuracies and caused addi onal “strain interna onal standards, the 2014 Census on the peace process at a cri cal me.”(13) remains the universally-cited popula on data for Burma. The census data on the The UN Popula on Fund (UNFPA) was the BPHWT Service Areas map are from the leading organiza on involved with crea on December 2015 update. and execu on of the census, which was es mated to cost approximately USD 74 Back Pack teams collect popula on data million to conduct. Although problems by house-to-house counts. The BPHWT- inherent in taking a census in Burma served popula on for Papun township is were known far in advance, iden fi ed 37,180 persons. BPHWTs serve a por on of concerns were not addressed nor were individuals within Hpapun township, not the specifi c poli cal and confl ict-related risks en re popula on. The Karen Department acknowledged; ethnic organiza ons were of Health and Welfare (KDHW) also never a part of the consulta on, dra ing provides healthcare services for a por on and planning process. of the popula on within Hpapun township not covered by the BPHWT. KDHW serves The Census resulted in massive undercounts 51,193 persons (14). The Burma census of the popula on in minority ethnic indicates a total township popula on of areas. Themes of inclusion, iden fi ca on 35,085. Individuals served by the BPHWT and access plagued the 2014 census: In and KDHW (s ll not the en re township Kachin, Northern Shan and Karen States popula on) total 88,373 minority ethnic in areas of ac ve fi gh ng between ethnic people, more than double that reported by armies and the Burma army or in areas the census. This is but one illustra on of the under the protec on of ethnic armies, no inaccuracy of the Burma 2014 Census. data was collected. In Arakan State, those who asked to be recorded as “Rohingya” Since the inten on of the 2014 Census was were instructed to iden fy as “Bengali.” to support the development of policy and If individuals insisted on being listed as programs and to guide resource alloca on Rohingya, the census taker collected no for the people of Burma, the 2014 Census is data whatsoever. Throughout the country, not a reliable mechanism to do so. Minority mul ple discrepancies occurred including: ethnic people — especially those living in lis ng of non-existent ethnic groups, ethnic remote and vulnerable areas and confl ict groups listed under diff erent names in zones — have been widely under counted. diff erent regions, pairs of ethnic groups 22 Map of BPHWT Service Areas

Nanyun Hpakan ² Mansi Namhkan Manton Falam Lashio

Ta ngy an

Mongkaung

Kunhing Kyauktaw

Mawkmai Township BPHWT Nay Pyi Taw-Pyinmana Population per Township Population PekonLoikaw 2014 Burma Served* Demoso Census* Hpruso Thandaunggyi Bilin 181,075 10,861 Dawei 146,964 8,759 Htantabin Mese Demoso 79,201 9,101 Kyaukkyi Falam 48,077 2,510 Hpapun Hlaingbwe 265,883 28,242 Shwegyin Hpa-An 421,575 3,976 Kyaikto Hpakan 331,708 9,697 Bilin Hlaingbwe Hpapun 35,085 37,180 Htantabin ThatonHpa-An Hpruso 29,374 5,112 Kawkareik Htantapin 145,792 2,154 Myawaddy Kawkareik 278,280 20,714 Kunhing 53,403 5,487 Kyainseikgyi Kyaikto 184,532 3,572 Kyainseikgyi 196,911 33,187 Ye Kyaukkyi 113,329 10,683 Kyauktaw 173,100 7,615 Lashio 323,405 1,759 Loikaw 128,401 2,870 Mansi 52,945 3,248 Dawei Manton 38,601 12,825 Mawkmai 33,810 3,767 Mese 6,319 2,871 Mongkaung 74,294 8,613 Myawaddy 210,540 5,902

* please see important explanatory a Namhkan 113,821 2,136 * please see noteimportant on preceding explanatory page Tanintharyi Nanyun 51,980 3,337 note on preceding page Nay Pyi Taw -Pyinmana 187,565 2,718 Pekon 103,590 8,595 Shwegyin 107,462 2,070 Tangyan 172,805 2,131 Tanintharyi 106,853 4,708 Thandaunggyi 96,052 13,150 Thaton 238,106 2,810 Ye 263,624 10,381

23 24 Birth of the Back Pack Health Worker Team

TradiƟ onal Beliefs, Modern Medicine A monk living at a monastery in the village became very sick. Everyone thought witches were visi ng him. Parents and family all refused to touch him. When Back Pack health workers met him we did a blood test and found he had malaria. We treated the malaria and he became strong again. Then the community realized there was not a witch, it was just malaria. -Sai Lao, Shan Field in-Charge

The 1988 na onwide pro-democracy ci zens to march and speak out against uprising in Burma, organized primarily by the repressive regime. The protests students, drew hundreds of thousands culminated in thousands dead and renewed of students, monks, children and other crackdowns on the ci zenry. It was amidst

Back Pack health worker providing Vitamin A Pa ent referral requires several people and to children much care!

Pa ent referral through the jungle Keeping a record of pa ent visits

25 communi es. Of her work at Moulmein Hospital where pa ents had to travel three to fi ve hours by cart or boat to reach the facility, Dr. Cynthia states, “It became clear to me that for rural popula ons, preven ve care was non existent and emergency services were not accessible. Government services were simply not accessible to all.” (15)

Data collec on is logged in a BPHWT fi eld Soon a er arrival in Thailand, Dr. Cynthia area established the Mae Tao Clinic (MTC). In 1991, responding to the massive need, this environment that the future founding MTC and partner organiza ons supported members of Back Pack Health Worker Team Mobile Medical Teams (MMTs), groups were emboldened to be er the situa on of ethnic health workers who journeyed for Burma’s ethnic minori es. into eastern Burma for six to eight weeks

One individual who fl ed Burma during this me was Dr. Cynthia Maung, Dr. Cynthia as she is fondly known. During her journey of seven days to the Thai border town of Mae Sot, Dr. Cynthia and others walked through countless villages where, upon hearing that she was a doctor, villagers rallied asking for care and treatment. Many of these villagers were struggling for basic survival; they had never enjoyed medical care of any kind. No en ty was providing services Just born by Tradi onal Birth A endant to this vulnerable popula on. Dr. Cynthia was no stranger to the need for health care to deliver health care and health care amongst Burma’s marginalized and rural educa on. The MMTs carried all medicines, equipment and supplies in backpacks as they trekked through the jungle to reach remote villages. MMTs were joined by members of the local community who were familiar with the terrain and able to navigate safe passage, and who could also assist in building trust between villagers and traveling medics.

MMTs had diverse du es and were deeply engaged with the communi es they served. Since MMTs could stay in one Back Pack health worker trea ng pa ent loca on for only a few days, it was essen al with boils that the health workers teach skills and 26 States. In this way, access to healthcare services in remote and vulnerable areas near Burma’s border grew. The MMTs operated from 1991 to 1997. As the Burma military increased a acks in the borderlands from 1997 through 1998, the challenges to providing safe and eff ec ve health care increased. Some workers were unable to safely reach villages that had grown to depend upon their visits; fi eld clinics had been destroyed or could no Delivering supplies through the river to the next Back Pack loca on best prac ces to community members; prac ces that some mes ran counter to tradi onal approaches to health care. When a pa ent needed to be transported elsewhere to facilitate more advanced care, the MMTs were tasked with explaining to local authori es why such a transport was necessary. A er traveling for three to six months, MMTs returned to the MTC where they received addi onal medical training.

Over me, MMTs included health workers from ABSDF and other ethnic health organiza ons in Karen, Mon and Karenni

Weighing the baby

longer operate. In 1998, following a series of mee ngs amongst interested ethnic organiza ons, the Back Pack Health Worker Team was formally established: Working together would allow greater collabora on and standardiza on of services and health care delivery. The Back Pack Health Worker Back Pack health workers enjoy suppor ng Team, a community-based, stable and their community! sustainable organiza on, was prepared to take on the mantle of this work.

27 28 New & Noteworthy: 1998-2018 Program Highlights, Lessons Learned, New Challenges to Address

IntroducƟ on

The Back Pack Health Worker Team healthcare where it was not otherwise (BPHWT) was founded in 1998 with 32 a ainable, the BPHWTs provides a range of teams, 120 health workers and serving medical care, community health educa on a popula on of approximately 45,000 and preven on, and maternal and child minority ethnic people. These dedicated healthcare services to internally displaced health workers traveled three ethnic areas persons (IDPs) and other vulnerable people such as Karen, Karenni and Mon. Since that in Burma. me, the BPHWT has steadily grown to encompass 113 teams, comprised of 456 Since the prac ce of medicine in Burma medics, 799 Tradi onal Birth A endants / requires specifi c government-approved Trained Tradi onal Birth A endants (TBAs/ training, degrees and accredita on, it TTBAs) and 281 Village Health Volun tes should be noted that merely working / Village Health Workers (VHVs/VHWs). as a medic in Burma (and without such We now support nearly 300,000 minority accredita on), is a revolu onary act; those ethnic Burmese. Our eff orts reach and who digress from this proscribed system contribute to the health and well-being of are in viola on of the law. There also may people in all seven states and three regions, be a percep on that anyone empowering encompassing 21 fi eld areas. the rural ethnic popula on with educa on and health care must be working for the The founders of the BPHWT were health ethnic army. Over the years, encounters workers from Karen, Karenni and Mon between the BPHWT health workers and areas. Created to provide quality free the Burma military have not always been or low-cost primary and confl ict-specifi c cordial. the BPHWT health workers have at

Villagers receiving healthcare by Back Pack Back Pack health worker cleans a wound health worker 29 A malnourished child with complica ons of EPI delivery by a Back Pack health worker measles receives care

A large gash in the heel — before and a er receiving care various mes been dealt with harshly: the Clinics include examina on rooms, storage movements of health workers have been for medicines and some have addi onal impeded, workers have been harassed, equipment available such as an ultrasound ques oned, medicines and other materials machine. Notably, much like the villages have been taken and destroyed, people they support, these clinics do not have have been arrested without cause, been electricity or running water. Equipment that assaulted, and killed. the BPHWT medics requires electricity is powered by generator, put their lives on the line daily in order to which is used judiciously and on a strictly care for and educate their communi es. as-needed basis. Clinics are staff ed by local BPHWT-trained community members; The BPHWTs now include 48 sta onary including an ac ve network of VHVs/VHWs teams or Public Health Centers. These and TBAs/TTBAs. The clinic network is teams staff “permanent” clinics, built helping to create an enduring infrastructure where condi ons are suffi ciently stable and that empowers the community and ensures secure. Sta onary clinics provide on-going that adequate health care and educa on care to more than twice the popula on are endemic to the way of life. than a mobile team is able to support.

30 1998-2003 of the factors and healthy habits infl uencing The BPHWT’s early years were characterized be er medical outcomes. S ll, most had by a growth in staff , scope and methodology. not yet fully incorporated these changes From 1998 through 2001, all care was into daily rou nes. The challenges of a life covered under the BPHWT’s overarching of displacement shaped the willingness to Medical Care Program. Team medics do what was necessary for posi ve health responded to a variety of primary healthcare outcomes. needs, chief amongst these being malaria, diarrhea and acute respiratory infec on. Mid-year 2000 marked a change in data collec on methodology and data points As early as 2000 medics reported evidence observed. In the fi rst two years of the of increased interest in health-related BPHWT’s history, data collec on was not issues and greater self-care amongst those standardized and there is li le enduring they served. Villagers were asking more and comparable morbidity and mortality ques ons; they had greater understanding data from this me. In 2000, the BPHWT partnered with Johns Hopkins University and a collec on tool was devised that was used in all fi eld areas. Teams of health workers mapped village tracts according to demography, geography and human resources. Although this par cular method of data collec on was not carried forward in subsequent years, this cemented the BPHWT’s commitment to standardized, thorough data collec on.

In 2000, the BPHWT offi cially included Tradi onal Birth A endants (TBAs) among its ranks, a cri cal role within the village. There were 55 TBAs in the BPHWT service areas at that me. Vitamin A and iodized salt was added to pregnancy care kits used by the TBAs. Although TBAs were added to the rooster in 2000, systema c training of this important group did not begin un l four years later.

In 2001, the BPHWT responded to its fi rst documented emergency, a cholera outbreak outside the BPHWT area. A team of nearby medics launched an immediate response to Dooplaya, Karen State where 110 pa ents It is a group eff ort to carry the concrete were treated, with 76 deaths. Unfortunately cylinders used in construc ng water storage! three other areas experiencing an outbreak were unreachable.

31 educa on in confl ict zones required a very par cular a en on to safety. Under the assump on that they were working with ethnic armies to educate others, a villager caught with an educa on poster could be interrogated or harmed by the Burma military. Although the BPHWT workers knowingly assumed the risk of carrying educa onal materials, documenta on and data, they had con ngency plans for discarding this informa on if a risky A child’s hair is trimmed to allow head situa on arose. The villagers needed no wound to be treated further exposure to risk. It was decided that a er workshops or teachings, posters would be le in public places – schools, monasteries, even on trees, so danger to The School Health Educa on Program individual villagers would be reduced. (SHEP) was piloted in January 2001. The program was established to address issues In 2001, reproduc ve data was collected that came to light in the Water & Sanita on for the fi rst me with the intended use for Survey: building latrines and hand washing a future Maternal and Child Healthcare facili es in schools, teaching about latrine Program. At this me, data points were use, brushing teeth, hand washing and not yet clearly defi ned and the integrity of distribu on of iodized salt (for brushing documenta on was variable. An important teeth) and soap to schools. lesson was learned, those collec ng data needed to be thoroughly trained to ensure In addi on to teaching school kids about consistent and usable data. hygiene and clean/safe water, eff orts were afoot for health educa on to the broader By the close of 2001, the BPHWT counted community. Toward this eff ort, the Women among its ranks 60 teams comprised of 182 Employment Advance Educa on (WEAVE) medics and 200 TBAs. The BPHWT became supplied educa onal materials and posters. aware that many TBAs were illiterate and It soon became obvious that health recording of data was both challenging and,

First an injec on is made, then Back Pack health workers operate on this woman’s large abscess

32 when it did occur, rife with inaccuracies. The Global Health Access Program (GHAP) and Dr. Cynthia Maung began work to develop a usable data collec on system for TBAs.

Also in 2001, fi ve Back Pack teams were intercepted by the Burma military. All medicine and supplies were taken and one medic was arrested.

In 2002, the BPHWT began the year with three dis nct and targeted programs: BPHWT birth records include baby’s Medical Care Program (MCP), School footprint Health and Educa on Program (SHEP) and Maternal and Child Healthcare Program (MCH). In 2002, the BPHWT was able to support, educate and heal 140,000 people! was introduced. Also in 2003, the home offi ce in Mae Sot began a formal Capacity Building Program for staff training. *since the BPHWT was established in mid-1998, 2003 marks fi ve complete years

2004-2008 2004 In keeping with the mission to work towards a long-term sustainable development of a primary healthcare infrastructure and empower local communi es, in 2004, the BPHWT workers give hygiene educa on and BPHWT established the Village Health distribute a toothbrush and toothpaste in Volunteer training. These volunteers, school trained at a more rudimentary level than the BPHWT’s medics, provide on-going and locally-based support and care to their In 2002, the BPHWT began an extensive de- worming eff ort. Higher incidences of worms are recorded as medica on administra on and closer monitoring iden fi es previously overlooked cases.

A er fi ve years* in 2003, the BPHWT had more than doubled the number of teams to 70, increased the number of medics to 250 and, for the fi rst year, counted amongst its number 20 Maternal and Child Healthcare in-charges. A family planning program including educa on and Concrete cylinders are placed to build the distribu on of reproduc ve health supplies base of a latrine 33 Also in 2004 the School Health Educa on Program (SHEP; some mes referred to as the Public Health Promo on Program) formally became Community Health Educa on and Preven on Program (CHEPP), a name that con nues to this day. Thus, all three of the BPHWT’s enduring Programs were fi rmly established: Medical Care Program, Community Health Educa on and Preven on Program, and Maternal and Child Healthcare Program. Back injury is cleaned and drained

communi es, in addi on to assis ng the BPHWT’s medics whenever possible. By the close of 2004, 204 Village Health Volunteers had received training. Although the BPHWT began training of TBAs in 2000, a need for more consistent and structured training had become apparent in the ensuing four years. This systema c training of Tradi onal Birth A endants began in 2004. Eye care is a rou ne component of primary In addi on, in the fi rst center of its kind health care established by the BPHWT, a “Public Health Center” in Kayah and Kayan areas was established for outpa ent care; it was staff ed by two BPHWT medics and open 2005 fi ve days each week. An escala on of Burma military a acks on the Karen Na onal Union (KNU) in the second half of 2005 led to widespread displacement and a doubling of gunshot and landmine injuries. One medic was arrested and imprisoned.

Extensive trainings were held in 2005: 21 Village Health Volunteer trainings were off ered with hundreds more volunteers joining the VHV ranks; 138 schools received educa onal sessions on water and nutri on with 381 teachers and 9409 students a ending; and, 318 TBAs were trained. In December the BPHWT off ered World AIDS Back Pack health worker administered to Day ac vi es for the fi rst me, an eff ort pa ent with allergic problem that has con nued yearly. 34 Thailand BPHWT relies upon interna onal organiza ons and individuals to donate this (and other) important medicine. In 2006 an insuffi cient quan ty was donated to meet the needs of the BPHWT’s target popula on.

Repeated a acks by the Burma military had a profound eff ect on all areas of the BPHWT ac vi es in 2006 — from health worker travel, to transporta on of supplies, Back Pack health worker helps to clean this to health care data and documenta on. In child’s skin infec on yet another related by-product of work within the confl ict zone, three village health volunteers were arrested and jailed 2006 by the Burma military; other village health In 2006, the BPHWT extended their service volunteers were forced to sign documents area with 6 teams serving Shan and Lahu indica ng they would no longer work with areas. The BPHWT also received requests the BPHWT. for support from Arakan and Pa Oh ethnic areas. In four years, from 2002 to 2006, the BPHWT documented a 70% decrease in malaria The use of para-check malaria test kit was morbidity; a marked 59% decrease in acute introduced as a pilot program in 2006. respiratory infec ons (average of mild and The de-worming program, an important severe ARI); a marked 73% decrease in countermeasure against malnutri on, was diarrhea and a 63% decrease in dysentery. extended to treat children as young as 1 year old. 2007 2007 saw greater growth and expansion as A typical logis cal challenge was pilot programs were introduced in Arakan encountered in 2006 with Vitamin A. and Pa Oh areas and four teams were added Since Vitamin A cannot be purchased in to Shan and Lahu areas.

Necro c skin is removed and nose is s tched up

35 Increased consciousness of gender inequity villagers were required to provide livestock prompts the addi on of the BPHWT gender and ra ons to the military on a regular policy and analysis and gender equity goals, basis. Burma military troops also freely recorded in 2007 and subsequent Annual took livestock without reimbursement and Reports. prohibited villagers from leaving the village under threat of death. If people refused to Although the para-check malaria rapid par cipate, they were fi ned or tortured. test was widely available, in 2007 malaria Human rights abuses are summarized in morbidity doubled in Dooplaya area due to the BPHWT’s Annual Reports. forced displacement, food insecurity and lack of sanita on. An upsurge in violence During 2008, two villagers being used as led to further displacement and a doubling guides stepped on landmines; one was in landmine injuries in Karen State. killed, one lost his legs. Four villagers forced Four teams had their medical supplies to carry food for Burma military troops confi scated by the Burma military. Three stepped on landmines, two were killed, medics were arrested. two lost their legs. One medic was arrested and released upon payment by family. One 2008 Maternal and Child Healthcare worker was In 2008, the BPHWT began detailing human arrested. rights abuses that the BPHWT communi es experienced. These included the taking of In 2008, a lympha c fi lariasis (LF) problem residences for use by the military; enforced was iden fi ed in Mutraw, Kler Lwee Htoo curfew and “lights-out” policy with military and Thaton areas. In response, a pilot orders to shoot anyone breaking curfew; program was ini ated in the Papun area forced use as guides, porters, sentry duty, of Mutraw where 71% of those tested fence building and clearing roads for were posi ve for LF. Half of the aff ected military; being forced to carry/deliver le ers; popula on was given medicine with the forced to cut and carry bamboo trees; build goal of providing medica on for the other camps and plant crops for troops; cook for half and also those in Kler Lwee Htoo and troops. Regularly money was extorted from Thaton areas in 2009. villagers; chicken or other food taken or

Health workers take/record mom’s vital A new group of Trained Tradi onal Birth signs while curious on-lookers watch A endants graduates! 36 Mul ple lacera ons on this man’s leg are cleaned and sutured

A spotlight on eye care prompted a workshop A fl u outbreak in Lu Thaw township, Papun a ended by 24 medics on eye anatomy, District was all the more devasta ng due vision checking, refrac on and pinhole to a Burma military lock down and “shoot- making. The BPHWT began providing on-sight” policy. Between September and eyeglasses for TBAs, many of whom were October 2009, the fl u spread to 35 villages. elderly and with failing eyesight. The BPHWT worked in collabora on with the Karen Department of Health and Welfare As the BPHWT hit the 10-year mark in and the Pa Hite Clinic to mount a response 2008, the BPHWT had grown to 78 teams to the epidemic. A Thai hospital also comprised of 290 medics; in addi on, the contributed to the eff ort with the dona on BPHWT was now working with 570 TBAs, and of infl uenza test kits and diagnos cs. 413 VHVs. The service area had expanded to include Karen, Karenni, Kayah, Kayan, 2010 Mon, Shan, Lahu, Arakan and Chin areas for In 2010, three new teams were deployed to a total of 160,000 served annually. Kachin, Shan-Kayah and Palaung areas. In July, a medic was killed by an Burma 2009-2013 military a ack in Karen State. 2009 In advance of the 2010 elec ons, 2009 The BPHWT worked in collabora on with saw increased militariza on and a empts the Burma Medical Associa on, Na onal by Burma military forces to convert ethnic Health and Educa on Commi ee and health organiza ons into emissaries under Burma organiza ons serving Karen, Karenni, Mon, military control. Increased confl ict caused Shan and Palaung communi es to plan, instability, forced displacements and design and implement a health and human increases in human rights viola ons — a rights survey in Eastern Burma. The results challenging environment for the BPHWT’s of the study were published in October communi es and health workers alike. 2010 as Diagnosis: Cri cal — Health and Human Rights in Eastern Burma. S ll, need for the services that BPHWT provided could not be curbed, and a pilot Following November elec ons, armed program was established in the Pa Oh confl ict and human rights viola ons soared. area. Many rural ethnic communi es were 37 Also in 2011, the BPHWT off ered its fi rst trauma management training course focused on emergency and confl ict-related health care.

2012 Twelve new teams were added to BPHWT in 2012, in Palaung, Kachin, Pa Oh, Shan, Win Yee, Papun, Kler Lwee Htoo, Kayah and Dooplaya areas.

As part of her rou ne care, a woman with a The BPHWT mounted emergency responses large goiter has her blood pressure taken to three health and natural disasters in 2012: Flooding in Kyauk Kyi Township in Kler Lwee Htoo area caused food shortages, tainted displaced and a mass exodus in Eastern water and poor sanita on. The BPHWT Burma surged toward the Thai-Burma responded with provisions of rice, chlorine, border. Working with the Mae Tao Clinic soap and a workshop on hygiene, sanita on, and Burma Medical Associa on, mobile clean water and disease preven on. “outpa ent department clinics” (OPDs) were established near the border to off er A measles outbreak in Pa An District health care and assistance to displaced eff ected about 500 people in three people; each OPD was stocked with villages. Six BPHWT health workers off ered medicine and supplies and staff ed with 3-5 a coordinated response with the Karen experienced medics. Department of Health and Welfare and the Karen Na onal Union; about 20% of the 2011 eff ected popula on was treated. In 2011, four new Back Pack teams were created to serve in Palaung, Arakan, Kayan In Tae Bo Hta and 10 nearby villages in the and Shan-Kayan areas; 2 teams in Lahu Papun area, an infl uenza outbreak aff ected area were discon nued. Two medics were arrested and detained for nearly three months.

Malaria treatment changed to use of fi rst line drugs: arteminisin combina on therapy led to an 18% decrease in malaria morbidity since the previous year; under 5 years old morbidity decreased by 35%. Screening for malaria became a rou ne aspect of preventa ve care for all pregnant women; when possible, women were screened twice during pregnancy.

Infected wound is cleaned and drained

38 Group (HCCG). The HCCG seeks to develop a plan to converge the extensive network of community-based organiza ons, ethnic health organiza ons and border-managed health systems with the Burmese na onal health system and to form an inclusive and thorough delivery of healthcare. For more informa on on the work of this important group, see “Building Coali ons for Las ng Change.”

Stones of mul ple sizes are gathered and 2013 prepared for use in a water fi lter On-going stability and security supported the growth of the BPHWT’s sta onary teams in 2013 with 24 new Public Health 4,107 people. Seven health workers and Centers established in Shan, Karenni, Karen one VHV responded to provide treatment. and Mon States and Tenasserim region. Five new mobile Back Pack teams were formed In a 2010-2011 review and evalua on to support Papun, Pa Oh, Kayan and Kler of the BPHWT’s work, the Burma Relief Lwee Htoo areas. Centre (BRC) noted that medics are limited to a stay of one to three days in any one In response to an assessment on maternal village due to the need to travel to other health and malaria management, the BPHWT villages on their route. In the eff ort to collaborated with Pa An-based Phalon create more con nuous health care, the Educa on and Development Unit (PEDU) BRC recommended that the VHVs receive and the re red Government Township addi onal training in tasks involving greater Medical Offi ce Nursing Matrons to off er an exper se and responsibility (thus extending extensive Auxiliary Midwife (AMW) Training training to three months, rather than one as a pilot project. The training consisted month) and be called Village Health Workers of four months of classroom instruc on (VHWs). This would empower the VHW to followed by a clinical training of three treat common diseases, provide follow-up treatment and determine within 24-hours of an individual with fever tested posi ve for malaria and begin immediate treatment. Training for VHWs began in 2012.

The BRC review also suggested that TBAs receive addi onal training and be called Trained Tradi onal Birth A endants (TTBAs); 57 TBAs received this follow-up training in 2012.

In the light of ongoing peace nego a ons in many ethnic areas of Burma, several health- Laying pipes through the jungle to bring related organiza ons came together in clean water to the village 2012 to form the Health Convergency Core 39 At the close of 2013, the BPHWT had 100 teams comprised of 351 medics. They were joined by 696 TBAs/TTBAs, 417 VHVs/VHWs for 225,000 people served.

2014-2017 2014 On-going clashes in Kachin State and Northern Shan State presented challenges to the BPHWT and the villages they served BPHWT supplies are piled high and ready for in 2014. Especially in the Palaung areas of transport Northern Shan State, the increased needs of displaced villagers added to the challenges of service delivery. months at the Mae Tao Clinic. Following the training, new AMWs returned to their communi es to implement a Maternal and Child Healthcare Program as outlined by the BPHWT. Both the survey and the pilot project were conducted under the aegis of the HCCG. Under government’s Rural Health Center structure, AMWs are not permi ed to perform deliveries unassisted, they must work with a midwife. However, since there is only one midwife for every 20,000 people, this arrangement is unsustainable; AMW do in prac ce perform deliveries solo. Increasing the number of well-trained Regular antenatal visits can help prevent AMWs is one means of providing readily problems accessible and much needed care.

In areas of temporary ceasefi re, medics were able to travel more freely but encountered frequent checkpoints and interroga on by Burma military. Ac ng with cau on due to military presence, some medics altered planned ac vi es. In the fi nal quarter of 2014, health workers in the Arakan Field Area were stopped and ques oned by the Burma military; they were told they needed to obtain permission from local authori es before engaging in their ac vi es.

In the Pa Oh fi eld area, armed confl ict RH awareness raising by MCH supervisor between two Ethnic Armed Organiza ons 40 Also in 2014, Maternal and Child Healthcare Program recorded the fewest maternal deaths since the program’s incep on (2004) and the fewest number of s ll births/ abor ons/neonatal deaths.

2015 In 2015, the Emergency Assistance and Relief Team (EART) was repeatedly pressed into service. The EART is the emergency response unit of the Forum for Tubing is placed throughout the village to Community-based Organiza ons of Burma bring clean water to all (FCOB). FCOB func ons as a collabora ve group off ering assistance to the ethnic community along the Thai-Burma border and the presence of land mines restricted who have experienced natural or man- access to a local village; medical services made disasters. could not be provided.

In 2014, the BPHWT began use of the SD Bioline test. This comprehensive malaria test checked for both plasmodium falciparum and plasmodium vivax malaria, thus suppor ng immediate treatment.

Also in 2014, both the presump ve and tested malaria caseload decreased drama cally to 2,308 (1%) and 1,614 (<1%) cases respec vely. Thumbprint sign-in to receive foods off ered through the BPHWT’s antenatal nutri on support program

- In June, land confi sca on and the destruc on of homes, food stores and personal eff ects in Upper Kawt Yin in Pa An township prompted the EART to supply rice, oil, mats, blankets, and mosquito nets to 83 households/393 people. The BPHWT provided support in collabora on with the 88 Karen Genera on Student of Development Social Associa on. Local villagers off ered guidance on geography and Providing humanitarian assistance to security concerns. Cyclone Nargis vic ms

41 items, protec ve shee ng, mosquito ne ng, water containers and other needed supplies.

- In October, the Burma military a acked Shan State Progress Party (SSPP)/Shan State Army-North near Wanhai Village, Monghsu Township a er the later refused to withdraw soldiers from that area. Approximately 6000 people were displaced. The Villagers listen to health worker at a BPHWT BPHWT provided medicine and Family Planning Workshop hygiene kits through a local partner, the Tai Youth Network.

- In July, fi gh ng between the Burma military and the Democra c Karen Buddhist Army (DKBA) along the Asia Highway near Kaung Mu Village led to displacement of 61 households/359 people. The BPHWT delivered emergency ra ons.

- In late July, heavy rains caused massive fl ooding. The BPHWT and partner organiza ons provided ra ons, clothing, chlorine, personal hygiene Expectant moms and kids receive yellow bean, eggs and oil to support a healthy pregnancy

- Further rains in October caused a landslide in Mawchi Taung Paw village, Hpa Saung township in which 17 people died, 48 were injured, 30 were missing and 4,000 were forced to relocate. The BPHWT worked with youth community service organiza ons to deliver nned fi sh, cooking oil, rice and blankets. The EART also delivered emergency medicine and hygiene kits.

In February 2015, the Health Informa on Informa onal posters cover the walls of a System Working Group (HISWG), a BPHWT clinic consor um of organiza ons that provide 42 2016 Responding to cri cal and unmet need in the target popula on, the BPHWT off ered two mental health workshops to health workers in 2016.

In 2016, the Back Pack health workers reported being stopped at checkpoints with increased frequency. O en they were required to present offi cial documents and pay fees in order to proceed with supplies. This occurred in several fi eld areas. In some areas the fee was dependent on the discre on of the offi cer on duty, in other loca ons, health workers were also required Baby with a fever receives a sponging to obtain permissions from immigra on, police and township General Administra on Department prior to conduc ng a training. Eastern Burma Retrospec ve Mortality This is adding to mission costs and health Survey (EBRMS) in Eastern Burma, published worker delays. the results of a study en tled, Long Road to Recovery: Ethnic and Community-based Health Organiza ons Leading the Way to Be er Health in Eastern Burma. Due to their fi nding that in 2013, 11.3% of women of reproduc ve age were moderately to severely malnourished, BPHWT’s Maternal and Child Healthcare Program began providing oil, yellow bean, eggs, canned fi sh, dried fi sh, iodized salt and sugar to pregnant women. The Program off ered support to pregnant women in 4 fi eld areas to combat malnutri on and improve pregnancy outcomes.

In 2015, the NLD’s Elec on Manifesto outlined several healthcare priori es that would lead toward the crea on of a universal healthcare system in Burma. The role of ethnic and community-based health organiza ons was no ceably absent, as was any men on of a movement toward a decentralized, inclusive system of health care. (This document has since been replaced by the NLD’s Na onal Health Plan, Health and Human Rights survey report published in December 2016.)

43 A medic from the Lahe Hospital administered treatment to the children. In addi on, a medic was dispatched from the Burma military who unfortunately arrived with insuffi cient medicine to address the aff ected popula on. The BPHWT’s fi eld in-charge and second fi eld in-charge were able to off er treatment to an addi onal 100 households in Kel San village, Nanyun Township. The outbreak was fi nally contained. Many modes of transporta on are used by Back Pack health workers to reach to Also in 2016, the BPHWT established the communi es fi rst Village Health Commi ees (VHCs) in Win Yee, Kawkareik, and Pa An fi eld areas. The VHC serves to empower the local As widespread drug use, especially with yaba and heroin, has been reported in the BPHWT tracts, the BHPWT is considering the best response to the growing drug addic on problem and the resultant diffi cul es it creates. Increased drug use and addic on has been accompanied by a spike in the violent crimes of rape and homicide. The Back Pack team o en encounter drug- addicted villagers when they become ill with diarrhea or other addic on-related side eff ects; health workers provide treatment of these side-eff ects when possible. Burns on this baby will be closely monitored to ensure they stay clean and uninfected In 2016, a measles outbreak occurred in the Nanyun and Lahe Townships in the Naga community by embodying par cipa on Field Area. and the on-going, sustained development of primary health care and posi ve health outcomes. The VHCs are responsible for pa ent referral, encouraging community empowerment and par cipa on, providing health educa on and oversight of clinic management, ensuring community sanita on needs are met, and coordina on with CBOs and NGOs. VHCs are also tasked with organizing quarterly regional mee ngs to communicate their ac vi es to the local community and seek input. Twenty VHCs Skin is thoroughly cleaned prior to have been established thus far with 198 treatment par cipants. 44 The BPHWT added three addi onal fi eld areas to the MCH Program for nutri onal support to pregnant women. The BPHWT now off ers nutri onal support to Taungoo, Thaton and Papun areas in addi on to Pa An, Kawkareik, Win Yee, Dooplaya fi eld areas. In its height, in August 2017, the BPHWT off ered food supplementa on to In order to treat skin infec on, dead skin is 1,144 women; 33% more women than the gently cleaned away BPHWT was able to support in its busiest month in 2016. In 2016, the BPHWT had grown to 113 Back Pack teams (including 48 sta onary In 2017, the BPHWT off ered gender- Public Health Centers), comprised of 359 based violence workshops to community health workers; also on the team were 741 TBA/TTBAs, 215 VHV/VHWs, and a total of 244,410 people served. Primary and confl ict-specifi c healthcare was provided in Karen, Kachin, Kayah, Kayan, Mon, Shan, Lahu, Arakan, Naga, Pa Oh, Palaung and Chin areas; Tenasserim Division and, por ons of Bago and Sagaing Division.

2017 In 2017, the BPHWT recorded a record 4,144 deliveries. Of these, there were only two maternal deaths and eight neonatal For BPHWT’s CHEPP, latrines, tubing and deaths. While any deaths are too many, other supplies are stacked and ready for these numbers indicate vast improvements transport on the river in antenatal care, nutri on, and well-trained birth a endants. members; a subject that had been introduced in previous reproduc ve health workshops, but never given its own pla orm.

In May and June 2017, the EART responded to a dengue hemorrhagic fever outbreak in the Kayah Field Area. Three villages and 849 people were aff ected. Health workers provided treatment to 231 villagers, performed demographic analysis and off ered health educa on.

A broken arm is stabilized with a bamboo Mul ple eff orts are afoot in the BPHWT cast areas to provide a shared delivery 45 Government-InsƟ tuted Health Care to the Rural Ethnic PopulaƟ on: not a formula for health The Burma Government opened a health clinic in the Palaung Field Area at Tar Nay Village with two government health workers. However, the government health workers do not staff the clinic full- me nor do they speak the local language. The clinic poses some obstacles to the con nued delivery of the BPHWT health services as requested by the local community. Also in the Palaung Field Area, there is a concern about the safety of Back Pack health workers delivering needed medical treatment and conduc ng health workshops due to the encroaching presence of the Burma Army. - Adapted from the BPHWT 2014 Annual Report

of healthcare, with varying levels of costs of transporta on and travel for coopera on and success. (To read their volunteers; serious malaria cases more about how the BPHWT envisions receive hospital referrals. For all other collabora on and partners as we move cases, ARC, CPI and the BPHWT work forward please see sec ons: Building together in pa ent treatment. Coali ons for Las ng Change and Fulfi lling Our Promise: the BPHWT look toward the - In the Kayan Field Area, the Back Pack future.) What follows are a few examples: team perform deliveries and Burma - In the Mon Field Area, the BPHWT government midwives provide free delivers babies while a Burma birth records as well as immuniza ons government midwife provides birth for women and children. The Karen records (at fee of 1,500 - 3,000 Kyat). Bap st Church runs a malaria Also working in this area are two program. INGOs: The American Refugee Commi ee (ARC) and Community - In the Pa An Field Area, near the Noh Partners Interna onal (CPI). ARC and Kwee Back Pack clinic, a local monk CPI provide malaria tes ng and cover has set up a sub-township health

Gloved medic s tches up a back injury An intake interview is a fi rst step in every medical consulta on 46 kyat). The Burma government has established a clinic near the Kwin Ka Lay Back Pack clinic. The government clinic provides immuniza ons, maternal and child healthcare and treatment. Government health workers receive pay of 100,000 - 200,000 kyat per month.

- In the Thaton Field Area, the Back Pack team deliver babies and provide A new and exhausted mother receives a birth records. The Burma government blood pressure check also provides birth records (for a fee of 3,000 kyat). The BPHWT’s birth records are not recognized by the center in Pa Khoh village. To help fund the health center, each household in the village is required to pay 6,000 kyat.

- In the Ta Naw Hta Back Pack team in Kawkareik Field Area, the Democra c Karen Benevolent Army has set up a clinic with fi ve health workers; one worker is a trained community health worker, and the others have not completed basic medical training.

- In the Dooplaya Field Area, Burma A healthy lifestyle includes a healthy weight government health workers provide birth records for a fee (3,000 – 5,000 Burma government. This has led to some individuals having two birth records. There is no communica on between government health workers and the BPHWT health workers. When in the same village, government workers communicate only with the head of the village. In this same fi eld area, the UNICEF has established a clinic near the Kyat Kart Chaung Back Pack clinic. The UNICEF provides maternal and child health care, immuniza ons and general treatment. The UNICEF operates independently An accurate inventory requires coun ng all and with no communica on with received medicine and supplies

47 Baby with complica ons from chickenpox Villagers wait to see the Back Pack health worker

either the government workers or though not exclusively, held by women. BPHWT. At the close of 2017, the BPHWT had teams In 2017, 59% of all posi ons in the BPHWT dispatched to 21 fi eld areas. These 113 were held by women, exceeding the BPHWT teams are comprised of 456 health workers, goal (stated in the BPHWT's by-laws) by 799 TBA/TTBAs, and 281 VHV/VHWs. A total 9%. This does not include Tradi onal Birth of 292,741 people were served in BPHWT’s A endants, a role that is tradi onally, targeted areas.

BPHWT works with Dr. Saw Nay Hser from Back Pack health workers travel to next the KNLA medical branch village for medical care to provide eye surgery.

48 TesƟ monials From BPHWT’s Field Areas

TesƟ monials from the Kachin Back Pack Teams

In 2017 a villager in the Wa Ra Zap village, was at this me that he came to the BPHWT Hpa Kant district, suff ered for more than clinic. The BPHWT’s medic consulted with one month from hand pain caused by the pa ent; the pa ent trusted the BPHWT infec on of an insect bite. He treated his medic. Through this process the pa ent hand pain with tradi onal medicine at his understood and accepted the medic’s home. However, he experienced extreme treatment. The medic performed the hand hand pain so he went to the government’s surgery and the pa ent’s hand healed. clinic at Wa Ra Zup village. There the clinic Currently his hand func on is normal staff told him he needed surgery for his and he is happy to be back to his life as hand and to go to Myint Kyi Nar Hospital. before. The community accepts and relies Upon hearing this the pa ent experienced on the BPHWT because BPHWT health stress and became depressed that he would care services are effi cient and achieve the lose his hand; he also did not have enough desired results money to get the suggested treatment. It

Kachin Field In-charge is providing surgical treatment to a pa ent in Kachin Field Area

49 TesƟ monials from the Pa An (Karen) Back Pack Teams

NAME: Saw Myint Htwe ETHNICITY: Karen JOINED BPHWT IN: 2012 POSITION: Pa An Field In-Charge

Meaning of Time

Time is a value of people which has been to my pa ent’s house. recognized by philosophers. But I don’t know how me has meaning for me because Because of raining season, it’s very diffi cult I don’t have a metable like other people to travel to my pa ent’s house since she to go, to come, and to eat. Everyone has lives in other village. But she needs my me. As for me, I would like to get free me help to save her life; so I keep going. When like other people, but I can’t seem to get I arrived at the pa ent’s house, I did an it. Time is very diffi cult for health workers examina on and took other history. Then like me. In morning, I must spend my me when I got the results from that, I saw that such as for cooking, preparing food for the pa ent needed to be referred to the my child, and taking them to school. A er hospital. I asked the pa ent’s family to fi nd that, it’s me to go to my work which is my a car and bring the pa ent to the hospital. pleasure. We needed a lot of people to follow us because transporta on is not easy - if the At a me one day in the morning, I heard car stops and faces any problem on road, we the telephone ring while I was preparing need people to push the car. Also when we food for my child. I thought it was maybe arrive at hospital and if the pa ent needs a a pa ent telephoning me. It was as I had blood transfusion, we may get blood from thought. This call to me was by one of my them. pregnant women to deliver a baby. It was an emergency case. So I had to go immediately When we arrived at the hospital, we hoped that the pa ent would be safe in delivery there. We needed the doctor to exam and operate on the pa ent quickly. We were very worried about the pa ent when she went into the opera ng room. Then the pa ent came out from the opera ng room and we saw that both the baby and mother were healthy – there were no problems with them. So we became very happy. A er we saw that the pa ent and baby were in good condi on, we returned to our village. Thus, it is diffi cult for health worker who want to give good health care to their community to have a personal metable like other people. Because of this, it is also not easy for health workers to have free me. 50 TesƟ monials from the Thaton (Karen) Back Pack Teams

Saw Thein Tan and Naw Tha Dar, who live in worrisome for the baby. I had planned to go Thaton District, Tha Gay Laung village tract, back as soon as I made sure the mother and Min Saw village, delivered Naw Tha Yu Paw the baby had safely arrived to the hospital. in Thaton Public Hospital on 28 November However, I decided to accompany them 2016. A er the delivery, a tumor was found because the mother was sick and did not growing inside of the baby’s nose as a result understand or speak Burmese.The baby of congenital disease. Therefore, we had to did not sleep the whole night and always refer the baby to Yankin Children Hospital. started crying if I was not holding her. When The doctor there said the situa on was very she cried, I looked at the fl uid dripping from her tumor and started crying too. I stayed with the baby for ten days in the hospital without sleeping. A er doing a physical examina on, we had to refer the baby to a be er hospital. The doctor at that hospital said “the baby is too young to do a surgery on her, but come back once every week for examina on”. The family’s income was mainly from farming so they could not make it to this appointment schedule because of fi nancial issues. I suggested that they to go to Mae Tao Clinic instead. On 16 January 2017, the family decided to go to MTC. A er examining the baby, MTC referred the baby to Chiang Mai Hospital on 17 January 2017. Presently, the mother and the baby are being cured at Chiang Mai Hospital. The family later thanked me for the medica on given to their child. I could not donate any money for the baby, but I feel good for myself that I was able to help the family by A mother with her child who is suff ering the referral to Mae Tao Clinic. from congenital disease

51 52 Three Sustaining Programs, Three Major Illnesses Back Pack Health Worker Teams Sustaining Programs: Medical Care Program Maternal and Child Healthcare Program Community Health EducaƟ on and PrevenƟ on Program

Health is Wealth The community needs to know that health is important! If you have a health problem, you can lose everything. Health literacy means how to implement good health for the people. Preven on and educa on is what we want to teach. - Khaing Myo San, Arakan Field in-Charge

The BPHWT employs a variety of measures Program, and Community Health Educa on and prac ces that enable preven on and and Preven on Program. treatment of disease and illness, a system of referral for cases beyond the capability The BPHWT’s pillar and original program is of its workers and other programs to the Medical Care Program (MCP). Workers support sustained health and sanita on are trained to care for and ac vely track in the community. This work is embodied 32 categories of illness and injury. In in three main programs: Medical Care addi on to provision of care and necessary Program, Maternal and Child Healthcare medicines, the MCP includes facilita ng

Working at night without electricity is an addi onal challenge for Back Pack health workers. Assembling pipes to bring clean water to the Electricity is essen al to strengthen the village health care system.

53 The Community Health EducaƟ on and PrevenƟ on Program (CHEPP; an expansion of the School Health Educa on Program pioneered in 2002) off ers workshops and educa on-related ac vi es both within schools and to en re communi es. Workshops are off ered on a variety of topics, including: malaria and diarrhea preven on, hygiene and sanita on, malnutri on educa on and reduc on, high-risk pregnancy, breast feeding best-prac ces, In dry season, risk of acute respiratory HIV/AIDS educa on, nutri on awareness, infec ons increases WASH (water, sanita on and hygiene) awareness, and preven on and awareness referrals when a situa on is outside the of communicable diseases. As an adjunct scope of the BPHWT health workers and to educa onal off erings within schools, responding to disease outbreaks and the BPHWT has ins tuted a Nutri on other emergency situa ons. The Maternal Sub-Program which provides de-worming Child and Healthcare Program (MCHP) medicine and Vitamin A to school children. was established in 2000 and provides Also included in the CHEPP is the Water care and nutri on to pregnant woman and Sanita on Sub-Program, established during the course of their pregnancies, in 2005. The Water and Sanita on Sub- post-natal support and care to infants and Program assists villagers in building gravity children up to age 5. This program includes fl ow water systems, shallow wells and training for locally-based Tradi onal Birth latrines. Village Health Commi ees (VHCs), A endants. Also included in the MCHP, a newer component to the CHEPP, meet are family planning ac vi es, reproduc ve quarterly with the community and enhance awareness programs and gender-based par cipa on, ownership, and sustained violence educa on to address these urgent support for primary health care on the concerns amongst its target popula on. village level.

Tracking morbidity across three prevalent illnesses The Back Pack workers are trained to respond to a variety of illness, disease and confl ict-related injury. In addi on, when a pa ent is in need of more intensive care, equipment, or medicine than the BPHWTs can provide, team members will endeavor to arrange a transfer to a facility be er equipped to deliver care. This is no simple ma er as jungle, mountains and torren al rains create environmental challenges, while ac ve combat and roadblocks Tes ng for malaria create barriers of a diff erent kind. Under

54 the best of circumstances the portering The health issues contribu ng most of a sick and injured pa ent, carried in a signifi cantly to morbidity and mortality in sling that is borne on the shoulders for a BPHWT fi eld areas are malaria, diarrhea, poten ally days-long walk, is diffi cult and acute respiratory infec on, anemia, worm dangerous for both pa ent and porters. infesta on and confl ict-related injury. For the pa ent who needs immediate and Three types of illnesses, and trends toward emergent care, me in transport and the wellness are traced here over our 20- condi ons of travel can worsen illness or year history: malaria, diarrhea and acute even hasten death. The job of the porter respiratory infec ons (ARI). can be demanding and relentless.

Malaria

In 2015, of the six countries in USAID’s many border areas. Greater Mekong Sub-region (Burma, Cambodia, China/Yunan Province, Lao In the early years, the BPHWT provided People’s Democra c Republic, Thailand the only opportunity for malaria tes ng and Viet Nam), 75% of all recorded cases and treatment for its target popula on. of malaria were in Burma (16). In addi on, The BPHWT documents a promising trend the Thai-Burma border has the dis nc on of improvement in disease transmission, of being the area with the most drug- detec on and management. Over 300 resistant falciparum malaria in the world. townships are s ll considered “high risk” During rainy season malaria rates typically (defi ned as greater than 1 case per 1000 skyrocket, raising the incidence of malaria people) — especially in Kachin and Rakhine as much as 30% (17). In an eff ort to frame its States and Sagaing Region (18). However, commitment to addressing this problem, those in the BPHWT fi eld areas have noted Burma has signed on to a Na onal Malaria a steady and striking improvement in Elimina on Project, seeking to eradicate malaria rates. These fi gures point to more malaria in Burma by 2030 — a tall order than a promising trend, they indicate a considering the prevalence of disease in spectacular improvement in the BPHWT

Villagers gather to receive Long Las ng LLITNs for youngest members of the family Insec cite Treated Nets (LLITNs) is a BPHWT priori za on

55 fi eld areas: from 2003 to 2017 a 93% comprehensive and on-going a en on to improvement was documented in number malaria preven on. of cases per 1000. (It should be noted that in data in 2003 and 2004 refl ects numbers Mul ple actors from a variety of countries, for presump ve malaria only; tes ng began NGOs, INGOs and the Burma government in 2005.) For the 10 years from 2007-2017, are currently involved in malaria preven on, a 89% improvement was documented, from treatment and eradica on eff orts in Burma. 76 cases per 1000, to fewer than 9 cases The Back Pack team serve in some areas per 1000. This improvement embodies where other malaria services are off ered; change on mul ple levels: incorporated in these loca ons coordina on of eff orts shi s in habit and a tude with respect to is handled with varying degrees of success. preventa ve prac ces as well as increased Some examples are men oned in the access to tes ng and medicine. It also sec on en tled: “New & Noteworthy: refl ects communi es that have greater 1998-2017 Program Highlights, Lessons stability and thus condi ons that support Learned, New Challenges to Address.“

Diarrhea

Like many of the most prevalent diseases amongst the BPHWT communi es, diarrhea is easily preventable given the proper condi ons. However when water may be contaminated, sanita on poor and educa on lacking on how to swi ly replenish depleted bodily fl uids, diarrhea can become a medical emergency. Worldwide 2,195 children under 5 years of age die each day from diarrhea-related problems — more than deaths from AIDS, malaria (19) Good hygiene, including trimming nails, and measles combined . Persistent or helps avoid the spread of disease frequent episodes of diarrhea can eff ect childhood growth and development (20). Of these deaths, 88% of the cases of diarrhea are a ributable to tainted water or poor sanita on (21).

While these reports focus on children, the dangers to adults of contaminated water and poor sanita on are just as deadly. And, adults without adequate sanita on prac ces further risk impac ng the health of countless others, as they prepare food and handle objects at home and in the community. The BPHWT’s Breas eeding Sick child is examined Workshops contribute to a lowering of 56 may not be able to aff ord the necessary materials for such construc on. This is exacerbated by encroaching development interests that are introducing pollutants into groundwater and toxins to the air.

Under adverse condi ons, diarrhea management and treatment becomes vitally important as eff ects can soon create a cri cal and life-threatening situa on. The BPHWT treat diarrhea and also provide educa on to communi es, especially to those living within challenging Villagers pitch in to build a concrete water storage circumstances, to create the best possible environment for health to fl ourish. Toward this end, the Community Health Educa on diarrhea because as mothers move away and Preven on Program (CHEPP) teaches from water-based sources for infant about personal hygiene and how and feeding, the risk of contamina on lowers where to build wells and latrines. Over the drama cally. years the BPHWT has lowered the rate of diarrhea by 57%; s ll, in 2017, 18 of every For vulnerable communi es living in confl ict 1000 people experienced diarrhea. This zones, lack of stability may compromise number has fl uctuated quite a bit over the the eff orts necessary to ensure thorough years as condi ons (both environmental sanita on, clean water and sustained and human-made) have changed. There benefi cial hygiene habits. Individuals forced is s ll much work to be done. Without to fl ee on a regular basis may not have the sustainable peace and sovereignty over opportunity or the will to build permanent one’s land and community, the struggle to structures that support good health. Others manage diarrhea will con nue.

Acute Respiratory InfecƟ on (ARI)

Respiratory infec ons are those infec ons of the upper airways (ear, nose, throat, trachea and bronchi), and the lower respiratory tract (lungs and smaller airways). These infec ons can be viral, bacterial, parasi c or fungal in origin and, depending upon loca on and origin, will have diff erent treatment protocols.

While upper respiratory infec ons spread quickly and their eff ect may be widespread in any given community, their burden is Back Pack health worker examines a child rela vely minor and rarely life threatening. 57 cri cal disease, exhaus on/fa gue and the physical and psychological stresses of life in a confl ict zone — all of these create a pre- disposi on to pneumonia and other ARIs. The same factors that aff ect ARI infec on also increase the risk of ARI transmission and progression and severity of disease. In short, amongst the vulnerable popula ons BPHWTs serve, ARIs are a pervasive concern.

School health receive Vitamin A Many of the condi ons driving ARI are outside of the control of the BPHWT. From 2003 to 2017 the BPHWT improved The majority of ARI deaths and severe upon nearly 98 mild ARI cases per 1000 illnesses are acute infec ons of the lower people, to 63 mild ARI cases per 1000 – an respiratory tract, especially pneumonia. This improvement of nearly 36%. Severe ARI, dispropor onately eff ects the under 5-year- much more challenging to mi gate and old popula on, the elderly and those with more virulent when present, improved by a compromised immune systems. However, more modest, yet s ll signifi cant 27% over amongst popula ons where there is a high this same me period. Notably, the rate of degree of malnutri on, inadequate shelter severe ARI has fl uctuated markedly as a due to displacement and/or destruc on result of natural disaster (Cyclone Nargis, of one’s home, low rates of immuniza on for example) and during periods of renewed or delays in immuniza ons, diagnosis of fi gh ng and displacement.

WASH awareness raising in the community Framing is placed for a latrine

58 Human Resources and Capacity Building Program (HRCBP)

The BPHWT’s Human Resources and Capacity Building Program facilitates, coordinates, and provides essen al training in support of the organiza on’s three health programs as well as its Health Informa on and Documenta on Program, and organiza on development.

The following are a lis ng of many of the key trainings supported over the past twenty years in Thailand and Burma:

Type of Health Workforce Trainings

Dura on No Training Titles Theory Prac cal 1. Health Assistant Training (HA) 22 - months 6 - months 2 Medic Training 6 months 4 months 3 Basic Emergency Obstetric and Neonatal Care 4 months 6 months Training (BEmNOC) 4 Maternal and Child Healthcare Worker Training 3 months 7 months (MCHW) 5 Community Health Worker Training (CHW) 6 months 4 months 6 Auxiliary Midwife Training (AMW) 3 months 6 months 7 Trained Tradi onal Birth A endant Training 10 days 6 months (TTBA) 8 Pharmacy Management Training (PMT) 10 weeks 9 Village Health Worker Training (VHW) 1 months 10 Cer fi cate in Public Health Training (CPH) 6 months 11 Cer fi cate in Health Facility Management Training 5 weeks (CHFM) 12 Integrated Management of Childhood Illness 1 month Training (IMCI) 13 Master of Public Health (MPH) 1 year 14 Trauma Management Training (TM) 1 month

59 Medical Care Program - Community Health Worker Training Health InformaƟ on and DocumentaƟ on - Community Mental Health Training Program - Con nued Medical Educa on - Data Collec on and Health Informa on (Training of Trainer) Training - Medic Training (Training of Trainer) - Video Edi ng and Documenta on - Medical Refresher Training Training - Pharmacy Management Training - Photography Training - Trauma Management Training - SPSS and Microso Access Training - Basic Lives Support/First Aid Training - Global Informa on System Training (BLS) - Services Mapping Training - Forensic Medicine / Medico-Legal - Health and Human Rights Survey Training Training

Maternal & Child Healthcare Program OrganizaƟ on Development Training - Auxiliary Midwife Training - Basic Computer & Offi ce Management - Maternal & Child Healthcare Training Training - Basic Emergency Obstetrics and - Financial Management Training Neonatal Care Training (BEmNOC) - Business Administra on Training - Tradi onal Birth A endant Training Course - Integrated Management of Childhood - Community Organizing Training Illness (Training of Trainer) Course - Gender-Based Violence / Gender - Non-profi t Organiza on Development Mainstreaming Training Training Course - Leadership and Facilita on Skill Community Health EducaƟ on and Training PrevenƟ on Program - Health as Human Rights Training - Cer fi cate in Public Health Training - Project Cycle Management Training Course (Thammasat University and - Disaster Preparedness and Magway University) Management Training - Master of Public Health (Khon Kaen - Basic and Intermediate English University, Thailand) Language Training - Village Health Volunteer Training - Graphic and Layout Design Training - Village Health Worker Training - Nutri on Training

Cer fi cate in Public Health Gradua on Ceremony

60 Health Facility Management Course

BPHWT's Medic Refresher Training

AMW Refresher Workshop

61 62 Building CoaliƟ ons for LasƟ ng Change Health InformaƟ on System Working Group (HISWG), established 2002

Empowering Villagers People in the village are comfortable with Back Pack health workers. If there is a problem, they want to see the Back Pack health worker and not be referred to another loca on. The Village Health Workers (VHWs) have our cell phone numbers. If there is a problem when we are traveling to another village, they will call us and we will go there. One me they called us because someone in the village was in a coma from meningi s. We could not get back in me for emergency, so the Back Pack health worker instructed the Village Health Worker over the phone how to care for the person and what medica ons to give. The person recovered. - Mr. Z, Kachin Field in-Charge

The HISWG is a collabora ve venture of Collected data was ini ally published eight ethnic health organiza ons and in a 2006 document en tled, Chronic mul -ethnic community-based health Emergency: Health and Human Rights in organiza ons* working to assess and Eastern Burma. A subsequent research strengthen the health system for ethnic eff ort led to the publica on of Diagnosis: minori es in Burma. The HISWG seeks Cri cal – Health and Human Rights in to establish health workforce strategies, Eastern Burma in 2010. In 2015, the HISWG develop training curricula, iden fy service published its most recent report, Long Road gaps and needs, design and implement to Recovery: Ethnic and Community-Based projects and programs, and conduct health Health Organiza ons Leading the Way to surveys. Be er Health in Eastern Burma.

Beginning in 2004, the HISWG began collec ng broad, popula on-based, retrospec ve mortality and morbidity data as well as assessments of basic health indicators for internally displaced persons (IDPs) and remote communi es in Eastern Burma. The HISWG also documented human rights viola ons and the health consequences of these abuses for their target popula on. This composite data is especially important as it represents health informa on on IDPs and vulnerable people Data collec on and repor ng training that is unavailable elsewhere. 63 Chronic Emergency, the results of a health-related popula on data that is popula on survey in Back Pack target “offi cially” available is not representa ve areas and designed with the collabora on or inclusive of Bruma’s ethnic minori es, of the Johns Hopkins University Center IDPs and vulnerable popula ons on the for Public Health and Human Rights and borderlands (for further informa on on the CPI/GHAP, was cited by a public health under-coun ng of minority ethnic people. expert as “a scien fi c breakthrough” by see sec on tled “Understanding the clearly establishing signifi cant correla ons Popula on Data.” between human rights viola ons and adverse health outcomes. The report was Long Road to Recovery contains the results also notable as the surveyed popula on of a large-scale health survey covering remained inaccessible to NGOs and INGOs, 64 townships, 6,620 households and thus undeniably establishing the cri cal 456,786 people. Long Road documents a need for the BPHWT. trend of improving health outcomes post ceasefi re (as of 2011). Seventy percent of In Diagnosis: Cri cal, the HISGW built on par cipants reported receiving health care the work of Chronic Emergency, covering a from ethnic and community-based health larger area and including the Shan State and organiza ons; while only 8% reported Tenasserim region. In addi on, Diagnosis: receiving health care services from the Cri cal considers a broader range of Burma government. In a fundamental poli cal and confl ict situa ons throughout response to confl ict, persecu on and the area. The survey was undertaken by necessity, the report outlines the available 45 surveyors who traveled to 221 villages health care resources – a network of rural in 21 townships, located in four states and clinics and mobile medic teams provided by two divisions in Eastern Burma. In each ethnic and community-based organiza ons village, houses were selected at random for and opera ng outside of the government survey par cipa on. The study established health network. Long Road emphasizes that that the country’s recorded numbers for genuine and las ng healthcare recovery for health event (per WHO) diff er markedly all the people of Burma will come only with from the popula on surveyed (example: peace and large-scale government reform. the maternal mortality rate in Burma is 240 deaths per 100,000 live births (22); the *Organiza ons involved: equivalent fi gure for surveyed communi es - Back Pack Health Worker Team in eastern Burma is 721. Clearly, the (BPHWT) - Burma Medical Associa on (BMA) - Karen Department of Health and Welfare (KDHW) - Karenni Mobile Health Commi ee (KnMHC) - Mae Tao Clinic (MTC) - Shan State Development Founda on (SSDF) - Mon Na onal Health Commi ee (MNHC) - Chin Public Aff airs Commi ee (CPAC) Health Facility Assessment in the fi eld HISWG website: h p://hiswg.org/

64 Health Convergence Core Group (HCCG), established 2012

Encouraged by on-going ceasefi re dialogue between the government of the nego a ons in many ethnic communi es Republic of the Union of Myanmar and in Burma, in 2012 the BPHWT and seven the United Na onali es Federal Council other ethnic- and community-based health (UNFC), and also stressed the importance of organiza ons* came together to determine con nued humanitarian health assistance how a re-formed government health system in support of peace building at community could best include the exis ng and vital and state levels. network of ethnic and community-based health care. The HCCG dra ed a model for *HCCG Member Organiza ons: convergence of these currently separate - Back Pack Health Worker Team approaches, linking specifi c ac vi es to (BPHWT) stages of the peace process. Members of - Burma Medical Associa on (BMA) the HCCG are commi ed to being ac ve - Karen Department of Health and players in shaping a new decentralized Welfare (KDHW) system of government and ensuring that - Civil Health Development Network Burma’s ethnic minori es maintain agency (CHDN) over their own health services. - Mae Tao Clinic (MTC) - Mon Na onal Health Commi ee In 2013, the HCCG’s “Building Trust and (MNHC) Peace by Working through Ethnic Health - Na onal Health and Educa on Networks towards a Federal Union,” Commi ee (NHEC) outlined nine principles necessary to - Shan State Development Founda on support a fair and peaceful transi on to (SSDF) a federal healthcare system. The HCCG - Chin Public Aff air Commi ee (CPAC) expressed both a need for and interest in

Health System Development Seminar par cipated by EHOs leaders, MoHS offi cials and NLD leaders 65 Health Reform Towards a Devolved Health System in Burma organized by the HCCG

Ethnic Health Systems Strengthening Group (EHSSG; previously Health Systems Strengthening Working Group), established 2015

The WHO defi nes Health Systems of the health system and that leads to be er Strengthening as the process of iden fying health through improvements in access, and implemen ng the changes in policy coverage, quality, or effi ciency.(24) and prac ce in a country’s health system, so that the country can respond be er to In addi on to wider health system drivers, its health and health system challenges (23); the UNICEF has specifi ed that health and, any array of ini a ves and strategies system strengthening is about “sustained that improves one or more of the func ons improvements in areas of family care,

EHOs Coordina on and Donor Mee ng

66 preven ve services and cura ve care services and personnel), responsiveness to that produce equitable health, nutri on popula on need (through evidence-based and development outcomes for children, planning and programming), fi nancial and adolescents and women.” (25) This creates social risk protec on (through priori za on a system that is both resilient and and low-cost interven ons and eff ec ve responsive. referral systems), and improved effi ciency (via thorough review/improvement of The EHSSG is a network of ethnic and underperforming facili es, programs and community-based health organiza ons* workers). working together to improve the quality of and access to health services in Burma. The strategy of how to best meet the health It was established following an extensive care needs of Burma’s ethnic minori es is evalua on and assessment of health outlined in the EHSSG’s Essen al Package facili es conducted with the UNHCR of Health Services (EPHS). This plan, with Balanced Score Card. The EHSSG seeks to an intended 2-year on-going review, is

EHSSG Annual General Mee ng

expand and enhance the sustainability of considered to be the fi rst of its kind: an health care. It takes a holis c approach EPHS that has been wholly conceived and that is aligned with specifi c aims of ethnic developed by a coali on of non-profi t, organiza ons’ demands in confl ict-aff ected non-governmental organiza ons. The Plan regions. The EHSSG framework is designed outlines responsibili es for facili es at with a en on to access, equity, essen ality, village, township and district levels; and appropriate technology, community specifi c du es of Village Health Workers, par cipa on and empowerment. It is the Community Health Workers, medics, inten on of the EHSSG to look beyond Maternal and Child Health Workers, mere provision of services to the broader Advanced Emergency Obstetric Care health care system within Burma, including Workers, and Trained Tradi onal Birth governance, accountability and leadership. A endants. The EHSSG seeks to standardize and legi mize health worker services and The EPHS contains 11 primary service status via improved health care delivery areas: Maternal and Newborn Health, (through expanded access to heath care Child Health, Reproduc ve Health,

67 School Health, Preven on and Control for implementa on. They do indicate that of Communicable Diseases, Emergency eff orts are on going to dra such a package Health, Mental Health, Basic Eye and suitable for the en re popula on. Thus far Dental Care, Trauma Care, Management they have merely indicated broad areas of General Ailments, Preven on and of coverage, priori zing preventa ve and Treatment of Non-Communicable Diseases. public health interven ons as well as basic Each of these services is profi led along with inves ga ve and cura ve services in the the appropriate support services for each. areas of reproduc ve, maternal, neonatal, Support services include pharmaceu cal, child and adolescent health, nutri on, diagnos c, infec on preven on/control, communicable and non-communicable monitoring and Health Management diseases, injuries and mental health. Informa on Systems (HMIS), and emergency referral support. Currently all health workers within Burma must be trained and accredited by the Burma is currently faced with both the MoHS. As such, those trained by the BPHWT challenge and opportunity of a Na onwide and ethnic health organiza ons and well Ceasefi re Agreement and a Na onal Health prac ced within their targeted areas may Plan. While the ceasefi re agreement has be seen as prac cing outside of the law. not received universal support and exis ng Although the government does recognize ceasefi res are tenuous, there is hope that the presence of Village Health Workers (s ll the peace process will move slowly yet overseen by the centralized government steadily toward a peace that supports but held to a lesser standard of training cons tu onal reform, a Federal Union, than fully-cer fi ed medical personnel), the and a de-centralized power structure. The BPHWT and other ethnic health workers Na onal Health Plan, spurred by the WHO are some mes perceived to be members mandate for universal health care by 2030, of the ethnic resistance and, as such, risk clearly ar culates many of the challenges arrest, internment, torture and death. facing rural and minority ethnic people of Burma, yet it remains lacking in strategy *EHSSG Member Organiza ons: and detail. - Back Pack Health Worker Team (BPHWT) Within this environment, the EHSSG off ers - Burma Medical Associa on (BMA) both a plan and a cri cal knowledge base. - Karen Department of Health and Comprised of ethnic and community-based Welfare (KDHW) health organiza ons off ering healthcare - Mae Tao Clinic (MTC) in government-neglected areas of Burma, - Commi ee for Health and the EHSSG is best posi oned to outline Development Network (Karenni) the structures and train the workforce for (CHDN) eff ec ve healthcare delivery. Similarly, - Mon Na onal Health Commi ee they can best recognize the necessary (MNHC) creden als to legi mize current health - Shan State Development Founda on workers so these individuals can be fully (SSDF) recognized and vital contributors in the - Pa Oh Health Working Commi ee future. At this wri ng, the Ministry of (PHWC) Health and Sport (MoHS) has not specifi ed - Loi Tai Li Health Commi ee (LTLHC) any EPHS within the NHP nor a strategy

68 Fulfi lling Our Promise: BPHWT Looks Toward the Future

The BPHWT Field in-Charges Answer the QuesƟ on: What is the strength of the BPHWT? We reach and treat people in very remote areas that other organiza ons cannot reach; there is no health care there from government. We are a realis c, grassroots community organiza on. We are mul -ethnic. We have a deep understanding of our area — including speaking the local language, understanding current fi gh ng situa on, knowledge of local customs, tradi ons and supers ons. We involve Village Health Leaders, Village Health Volunteers, religious leaders, schools, civil society, other ethnic health organiza ons and ethnic armed organiza ons. For community to be healthy everyone must be aware of health issues. We help the community become in-charge of their own health care. We help prevent problem and sickness with teaching how to build water fi lters, wells and where and how to build latrines; we also provide supplies for building. The BPHWT is strong in our area because it is not project based — 1 or 2 years and then gone. The BPHWT bring con nuous support to help community become more healthy.

IntroducƟ on

As we look toward the future, the BPHWT health services and systems accessible envisions a well-coordinated array of to vulnerable people living in remote and border regions of Burma. As fundamental and indispensable service providers in the Burma government’s Na onal Health Plan, the BPHWT and other ethnic health organiza ons (EHOs) and community- based ethnic health organiza ons (CBEHOs) shoulder an awesome responsibility. A thorough assessment of current prac ce and an implementa on plan for the BPHWT’s future delivery of care presents a complex yet cri cal task.

How does this diff er from the life-saving work Listening to the fetus’ heartbeat the BPHWT has accomplished thus far? No longer simply seeing isolated villages, village 69 tracts or fi eld areas of needed service, we communi es to manage and address are swi ly entering a me that demands a health-related problems and concerns more all-encompassing view. As the Burma at a local level — as both consumers and government inaugurates a Na onal Health providers of care. Levels of care will be Plan and gears up for the approaching WHO iden fi ed and systems of referral and means goal of Universal Health Coverage by 2030, to access diff erent services well delineated. the BPHWT has an integral role to play. The In addi on, throughout the BPHWT fi eld BPHWT and other EHOs/CBEHOs must be areas a healthcare-literacy will be cul vated similarly astride such a plan, with our role via workshops, small groups and individual unequivocally stated. instruc on. In these forums, prac cal skills will be taught and informa on shared. In From a robust primary healthcare this way individuals will be empowered to infrastructure, the BPHWT along with maintain and strengthen personal wellness partner organiza ons will equip ethnic and raise healthy families.

CollaboraƟ on

In order to eff ect this vision, the BPHWT is commi ed to examining how we can more fully and eff ec vely collaborate and coordinate with other EHOs/CBEHOs. A thorough survey is needed of all health care resources, staff , means of delivery and service points in a given fi eld area. Care is delivered by a mul tude of actors and organiza ons across a range of levels and services. The roles, responsibili es and training of each service provider must be Teaching kids about health; distribu ng defi ned. Are the off ered services of a good Vitamin A and de-worming medicine quality? Does staff possess the needed exper se and training? If not, what is needed to enable staff to be well-versed in mechanism for eff ec ve and meaningful their respec ve areas? In instances where data sharing need to be established? a variety of actors and organiza ons work in the same area, how does everyone The current availability and exper se work together? Could communica on and of health workers must correspond to camaraderie be improved? What are the the healthcare needs of the community. cri cal documenta on prac ces and data Mapping geographic areas of coverage collec on points? When is it appropriate will help reveal service gaps and provide for informa on to be shared amongst informa on for future planning. It is providers? Is this happening in a systema c understood that services vary widely by and standardized manner or does a area. Since the BPHWT is mul -ethnic, mul -

70 of health worker do pa ents seek for ini al contact? What is the impact on choice due to factors of accessibility, preference and aff ordability? What can the BPHWT do to increase confi dence and trust in essen al providers in the system? Does pa ent feedback indicate a needed shi in the current model of delivery of care? Once needs are clearly understood, strategies can be devised to address unmet needs. Regular feedback and data review will enable us to remain current and responsive to trends and emergent needs. Some of this work is already taking place within the EHSSG and HISWG. See the “Building Coali ons for Opening ceremony for the BPHWT’s Naung Las ng Change” sec on of this document Kwee Clinic for more informa on. lingual and well established throughout Burma Government as Partner: the Burma, we have a unique role to play in the BPHWT currently partners with the Burma communica on and coordina on between government to off er services to individuals en es. in our target areas. The BPHWT’s Auxiliary Midwife (AMW) Training receives supplies Once a thorough survey reveals available (AMW kits) and technical support (trainers) staffi ng and services, duplica ons will from MoHS. On the state level, the Burma become apparent. In areas where mul ple government supports the Expanded organiza ons serve a community, how Program for Immuniza on (EPI), which can responsibili es be coordinated so brings 10 immuniza ons to children aged that essen al func ons are not duplicated and resources are best allocated? With collabora on, coordina on and networking between the BPHWT and others well delineated, it will be necessary to establish a method of on-going monitoring, evalua on and improvement. On-going assessment will enable the BPHWT to monitor deployment of workers, examine the loss and reten on of trained staff , inform training topics, and direct a cri cal eye on the u liza on of resources and services.

Recipients of healthcare services have much to tell us in terms of preferred service delivery points. Focus group discussions can enable us to be er understand the Ethnic groups working together for the needs of our target popula on. What type health of all!

71 2 to 12 years. In addi on, on several areas — including, elucida ng specifi c occasions, representa ves from the strategies and clearly acknowledging the BPHWT (and partner EHOs/CBEHOs) have role and authority of EHOs/CBEHOs. And, engaged in discussion with the Burma importantly, a solu on must be reached on government on the dra ing and logis cs for wres ng management from a centralized the Na onal Health Plan (NHP). We expect system of control to a decentralized system this par cipa on to con nue. Much work where EHOs can assume authority for remains before the NHP can off er any real budge ng, dispersal, and alloca on of healthcare changes in the BPHWT’s target funds for their areas.

Expansion of the Scope of Services

As the BPHWT collects and analyzes what is the level of acceptance and use informa on, it may spur an explora on of of these service providers? Are needed expanding the BPHWT spectrum of services. services readily accessible? How long does We are seeing growing numbers of pa ents it take to travel to these facili es and how is with hypertension, diabetes, tuberculosis, such travel accomplished? It may become and those who have experienced accidents apparent that a gap the BPHWT can fi ll is of various kinds. Who currently provides with select secondary level care. This would services in response to these needs and entail addi onal training and, in some cases, procuring medicines, facili es and equipment.

In the case of needed secondary-level care that the BPHWT is unable to provide and is not available locally, is the established referral network func oning well? Do all involved par es thoroughly understand both the resources available and the mechanisms for referral? Is addi onal

The BPHWT “ambulance” used for pa ent referral and other clinic needs. Along with the BPHWT monies, funds for purchase Our kids are the future – brushing teeth and included contribu ons from many members regular washing with soap will help make it of the local community. a healthy one! 72 training necessary to ensure that all players smooth process with all players ac vely and are comfortable and well versed in carrying quickly responding to pa ent need, or is out their roles? Referrals for life-saving care improvement necessary? Referrals require take place on mul ple levels depending on clear protocol and procedure in terms of the par culars of each situa on — from an policy, clinical management and payment. ethnic health center to a government facility These areas all need to be examined to or from a community to a township health determine best prac ce and ensure well- center. Some referrals require permissions trained staff . at village and/or hospital levels. Is this a

Expansion of the Scope of Services: ProgrammaƟ c direcƟ ons ReproducƟ ve Health Services

Within the BPHWT target area, most and necessary creden als to administer women of reproduc ve age will have at this medicine? least two children, some will have many more. Typically, childbearing years begin for Clinical management must be employed women between the ages of 18-22 (some to standardize procedures among health women begin earlier) and can extend into workers. Standardiza on can and should a woman’s 40s. A consistent and long- lead toward accredita on that will, in turn, standing area of a en on and concern enable stability and sustained services is pregnancies with high-risk labor and from the standpoint of the NHP. A clear delivery. The BPHWT’s Maternal and Child understanding of policy-level requirements Healthcare Program is cri cally important and standards can and should drive any and very busy. In 2017 alone there were training. Another facet of RH and sexuality 4144 births amongst our target popula on educa on that must be included is a — more than 11 per day! comprehensive response to and educa on

Expanded Reproduc ve Health (RH) services are a much-needed area for program expansion. In order to prepare for any such growth, the BPHWT must fi rst lay the necessary groundwork. A thorough survey will establish a clear blueprint for who can do what within the RH area. As an example, misoprostol is a controlled substance with a range of u lity. It can be used to induce labor, induce abor on and to prevent postpartum hemorrhage. At this me, the Burma government only permits use of misoprostol for preven on of postpartum hemorrhage. Who within the Back Pack health worker providing implant BPHWT network has the skills, knowledge to mother 73 Twin blessing A new baby delivery by MCH worker about gender-based violence (GBV). A needed interven ons including medical, thorough response to GBV necessitates social and legal services. iden fying exis ng and/or devising new and

Mental Health Services

The BPHWT has off ered mental health for those for whom personal hygiene and training to our workers on three occasions. sanita on have become a concern. The At this me 74 people have completed BPHWT's mental health services, as indeed this basic training, with 53 health workers is the case with all our off erings, are fully already incorpora ng skills learned in the integrated with primary health care. communi es they support. At the me of wri ng this report, 64 people in various fi eld The BPHWT would like to train addi onal areas are receiving mental health-related health workers in this area who can services. These mental health services subsequently off er those services within include community consulta on, individual the village tracts they support. Beyond this, counseling, case management and, when we would like to develop a system to train needed, ac vi es of the WASH program locally-based mental health volunteers thus empowering communi es to carry on this important work. As the BPHWT moves toward iden fying and training volunteers within the community, we will establish supports to assist and supervise them in these endeavors. This will include training, including documenta on and session notes, and technical and supervisory assistance. It is envisioned that a “training the trainer” approach will be used to concentrate a network of knowledgeable people within Training On Managing Some Mental the local community. A en on will be Disorders give to Back Pack health workers focused on ensuring that clients receive 74 appropriate medica ons and psychosocial will have senior staff they can regularly supports. In excep onal cases, due to communicate with in addi on to on-going severity or crisis, the BPHWT will help ered training. In this way, local people establish an appropriate referral for clients with a deep understanding of and trust with and train mental health volunteers in those aff ected will be able to support their how to access the referral system. Those community in an on-going and sustainable who are working in a supervisory capacity way.

Drug AddicƟ on, PrevenƟ on and RehabilitaƟ on Services

Increasingly the BPHWT is receiving fi eld Local ethnic leaders are eager to resolve reports of drug use, addic on and its this problem. Within the village and impact on the individual, family, village and tradi onal way of life, drug addic on is community. Some areas of Burma are major a complicated issue that largely has not producers of yaba (methamphetamine) and been openly addressed. The BPHWT would heroin (opium). Drugs are easily obtained like to establish a mul -faceted approach for nominal cost with some users as young to this problem, including drug resistance as 14 years old. Deteriorated health, income workshops, educa onal materials for loss, destruc ve and violent behavior, and distribu on within communi es, and a Drug suicide are only a few of the consequences Rehabilita on Center with a local governing that have been reported. Drug addic on body and staff of trained local workers. is a chronic, progressive disease that, le This could be accomplished through unaddressed, can result in death. a partnership with a local community organiza on.

Closing Ceremony of Community Mental Health Training in the Kayan fi eld Area

75 BPHWT's leading member study trip about community mental health in Sri Lanka

Eff ec ve treatment must address mul ple how to develop personal accountability needs of the individual to be eff ec ve; and responsibility for one’s ac ons; skill- these can include medical, psychological, building to support self-empowerment social, voca onal and legal needs. The and restoring personal confi dence; and, Drug Rehabilita on Center will be a place if necessary, re-training in poten al where those with drug addic on can employment opportuni es. During the fi rst undertake, in a safe and suppor ve term of treatment at the Rehabilita on environment, medically-managed Center there will be repeated assessments detoxifi ca on. When stabilized, individuals to ensure that the treatment is appropriate will engage in educa on on the eff ects of and eff ec ve for the individual, with drug use on body and mind. Educa on will necessary adjustments made. An individual also address high-risk behaviors and risk- plan for follow-up care will be dra ed that reduc on techniques. A en on will be given will u lize mental health workers and have a to personal care, hygiene, and re-building network of services clearly established and strength of body and mind. Individual communicated. In keeping with the village rehabilita on eff orts will be aimed at the approach to care, it is an cipated that the individual’s return to a produc ve and Drug Rehabilita on Center will involve happy member of the community. Steps family members as a vital and important to accomplishing this include: teaching support base for their loved ones.

Back Pack health worker visit to a mental health rehabilita on centre in the Kayan Field Area Genera ons of caring 76 NOTES

(1) CIA World Factbook, 2014. (2) World Health Organiza on, Global Health Expenditure Database, Data Explorer, WHO, h p://apps.who. int/nha/database/Select/Indicators/en (3) Medical SEA, June 2013, as quoted in Healthcare in Myanmar, Ipsos Business Consul ng, November 2013, Ipsos. (4) Healthcare in Myanmar, Ipsos Business Consul ng, November 2013, h p://www.ipsosconsul ng.com/ pdf/Research-Note-Healthcare-in-Myanmar.pdf (5) Ministry of Heath, Health Sta s cs In: Health in Myanmar 2014, pp. 142-151, 2014, Ministry of Health; as quoted in “Healthcare in Myanmar,” Nagoya Journal of Medical Science, 78. 123-134, 2016. (6) h p://www.irinnews.org/report/91761/myanmar-rural-healthcare-crisis (7) The years from 1988 to 2012; Myanmar Ministry of Health, 2012. (8) CIA World Factbook, 2009. (9) h p://www.msh.org/blog/2013/01/31/paying-for-health-and-innova ng-for-value-in-myanmar; the World Bank found that 93% of medical spending was out-of-pocket in 2012. (10) “Year in Review: Public Health in Myanmar,” Elliot Brennan, Teacircleoxford, 21 May 2018, h ps:// teacircleoxford.com/2018/05/21/year-in-review-public-health-in-myanmar/

(11) h ps://www.irrawaddy.com/news/burma/s gma-shortages-plague-mental-health-care-in-burma.html

(12) h p://www.unhcr.org/internally-displaced-people.html (13) h ps://www.crisisgroup.org/asia/south-east-asia/myanmar/coun ng-costs-myanmar-s-problema c- census

(14) Personal communica on, 14 May 2018 (15) Ten Years Report 1998 – 2009, Life, Liberty and the Pursuit of Health: A Decade of Providing Primary Health Care in Burma’s Displaced and Vulnerable Communi es, Forward, pp.1-2, Back Pack Health Worker Team (16) https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy- 2018/fy-2018-burma-malaria-opera onal-plan.pdf?sfvrsn=5 (17) h p://www.msf.org/en/ar cle/myanmars-rains-bring-30-fold-increase-malaria). (18) h p://www.dvb.no/news/burma-striving-malaria-free-2030/78737 (19) Lancet 2012; 379 (9832): 2151-61. (20) Arch Pediatric Adolesc Med, 2012 Sept. (21) UNICEF, Programs for Children: A report card on water and sanita on, Number 5, Sept 2006). (22) Trends in Maternal Mortality: 1990 to 2008. WHO 2010. Ra o for 2008. (23) Health system strengthening - current trends and challenges. Execu ve Board 128th session, Geneva, 17- 25 January 2011. (EB128/37). Available at: h p://apps.who.int/gb/ebwha/pdf_fi les/EB128/B128_37-en. pdf (24) Islam, M., ed. 2007. Health Systems Assessment Approach: A How-To Manual. Submi ed to the U.S. Agency for Interna onal Development in collabora on with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Ra onal Pharmaceu cal Management Plus. (25) UNICEF. UNICEF’s Strategy for Health 2016-2030. 2015. Programme Division; and, UNICEF. The UNICEF approach to HSS: a synopsis. HSS Unit, Health Sec on, Programme Division.

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Back Pack Health Worker Team Annual and Mid-Year Reports, 1998 – 2017 Behind the Silence: Violence Against Women and their Resilience, Myanmar, Research Report, Gender Equality Network, February 2015, h p://www.burmalibrary.org/docs21/GEN-2015-02-Behind_the_Silence-en-red.pdf Chronic Emergency: Health and Human Rights in Eastern Burma, Health Informa on System Working Group, 2006. Civil Society Gaining Ground: Opportuni es for Change and Development in Burma, Transna onal Ins tute, Amsterdam, The Netherlands, November 2011. Cons tu on of the Republic of the Union of Myanmar, 2008. Crimes in Burma, Interna onal Human Rights Clinic at Harvard Law School, May 2009. Deciphering Myanmar's Peace Process: A Reference Guide 2013, Burma News Interna onal, Thailand, 2013. Diagnosis: Cri cal Health and Human Rights in Eastern Burma, Health Informa on System Working Group, October 2010. Eastern Burma Ethnic Community Health System Review, A report from the Health Systems Strengthening Working Group, August 2015. Essen al Package of Health Services, Health Systems Strengthening Project by Ethnic Health Organiza ons (EHOs), Myanmar, May 2017. Dra document. Ethnic Confl ict and Social Services in Myanmar’s Contested Regions, Kim Jolliff e, The Asia Founda on, June 2014, h ps:// asiafounda on.org/resources/pdfs/MMEthnicConfl ictandSocialServices.pdf Ethnic Groups in Burma: Development, Democracy and Human Rights, Mar n Smith in collabora on with Annie Allsebrook, A report by An -Slavery Interna onal, 1994, h p://www.ibiblio.org/obl/docs3/Ethnic_Groups_in_Burma-ocr.pdf Founda on of Fear: 25 years of villagers’ voices from southeast Myanmar, Karen Human Rights Group (KHRG), October 2017, h p://khrg.org/sites/default/fi les/khrg_founda on_of_fear_english_full_report_october_2017_w2.pdf From Rice Cooker to Autoclave at Dr. Cynthia’s Mae Tao Clinic, Mae Tao Clinic, February 2010, h p://www.burmalibrary.org/ docs08/From_Rice_Cooker_to_Autoclave.pdf Health System Strengthening Strategic Plan: Eastern Burma 2016-2019, Burma Medical Associa on, Back Pack Health Worker Team, Commi ee for Health and Development Network – Karenni, Karen Department of Health and Welfare, Mae Tao Clinic, Mon Na onal Health Commi ee, Pa-oh Health Working Commi ee, Shan State Development Founda on, 2016. Human Rights Watch, World Report 2017: Burma, h ps://www.hrw.org/world-report/2017/country-chapters/burma IASC Guidelines on Mental Health and Psychosocial Support in Emergency Se ngs, Inter-Agency Standing Commi ee (2007), Geneva: IASC. Invisible Lives: The Untold Story of Displacement Cycle in Burma, Human Rights Founda on of Monland, Burma Link and Burma Partnership, August 2016. Listening to Voices: Myanmar’s Foot Soldiers Speak, All Burma Students Democra c Front, Chin Na onal Front, Kachin Independence Organiza on, Karenni Na onal Progressive Party, Karen Na onal Union, New Mon State Party, The Center for Peace and Confl ict Studies, 2014. Mental Health Among Displaced People and Refugees: Making the Case for Ac on at the World Bank Group, prepared by Patricio V. Marquez, Global Mental Health Ini a ve, Health, Nutri on and Popula on Global Prac ce (HNP GP), The World Bank Group (WBG), January 2017. Myanmar’s Enemy Within: Buddhist Violence and the Making of a Muslim ‘Other’, Frances Wade, Zed Books: Asian Arguments, 2017. Myanmar Na onal Health Plan 2017-2021, Ministry of Health and Sports, The Republic of the Union of Myanmar, December 2016. Restless Souls: Rebels, Refugees, Medics and Misfi ts on the Thai-Burma Border, Phil Thornton, Asia Books, 2006. The Long Road to Recovery: Ethnic and Community-Based Health Organiza ons Leading the Way to Be er Health in Eastern Burma, Health Informa on System Working Group, February 2015. The Poli cs of Aid to Burma: A humanitarian struggle on the Thai-Burmese border, Anne Decobert, Routledge, Taylor & 78 Francis Group, 2016. The Nightmare Returns: Karen hopes for peace and stability dashed by Burma Army’s ac ons, Karen Peace Support Network, April 2018, h ps://progressivevoicemyanmar.org/wp-content/uploads/2018/04/The-Nightmare-Returns-English-version. pdf WHO Essen al Nutri on Ac ons: Improving Maternal, Newborn, Infant and Young Child Health and Nutri on, WHO, 2013. World Jus ce Project: Myanmar, h p://data.worldjus ceproject.org/#groups/MMR P. Bolton, C. Lee, EE Haroz, L. Murray, S. Dorsey, C. Robinson, et al. (2014), A Transdiagnos c Community-Based Mental Health Treatment for Comorbid Disorders: Development and Outcomes of a Randomized Controlled Trial among Burmese Refugees in Thailand, PLoS Med 11(11): e1001757. h ps://doi.org/10.1371/journal.pmed.1001757 Tina Y Falle, Luke C. Mullany, Nandita Tha e, Subarna K. Khatry, Steven C. LeClerq, Gary L. Darmstadt, Joanne Katz, James M. Tielsch, (2009), Poten al Role of Tradi onal Birth A endants in Neonatal Healthcare in Rural Southern Nepal, Journal of Health Popula on and Nutri on, Vol 27, No. 1. Timothy Holtz (2016), Medical care and social jus ce in the jungles of Myanmar, The Lancet, Volume 388, Issue 10058, pp. 2345 – 2347. R. Lakshminarayana, “Psychiatry to Psychosocial: Lessons from disaster mental health in India,” In: J.O. Prewi Diaz, R. Srinivasa Murthy, Rashmi Lakshminarayana, (eds.). Advances in disaster mental health and psychological support. Voluntary Health Associa on of India Press, New Delhi, 2006, pp. 108-126. Nyi Nyi La , Su Myat Cho, Nang Mie Mie Htun, Yu Mon Saw, Myat Noe H n Aung Myint, Fumiko Aoki, Joshua A. Reyer, Eiko Yamamoto, Yoshitoku Yoshida and Nobuyuki Hamajima (2016), Healthcare in Myanmar, Nagoya J. Med. Sci. 78, pp. 123-134. Lim et al. (2013) Trauma and mental health of medics in eastern Myanmar’s confl ict zones: a cross-sec onal and mixed methods inves ga on, Confl ict and Health, 7:15. Sharon Low, Kyaw Thura Tun, Naw Pue Pue Mhote, Saw Nay Htoo, Cynthia Maung, Saw Win Kyaw, Saw Eh Kalu Shwe Oo & Nicola Suyin Pocock (2014) Human resources forhealth: task shi ing to promote basic health service delivery among internally displaced people inethnic health program service areas in eastern Burma/Myanmar, Global Health Ac on, 7:1, 24937, DOI: 10.3402/gha.v7.24937. Kirsten McConnachie “Governing Refugees: Jus ce, Order and Legal Pluralism,”Chapter 6 in The struggle for Ownership of Jus ce, Routledge, Taylor and Francis Group, A GlassHouse Book, 2014. Luke C. Mullany, Catherine I. Lee, Palae Paw, Eh Halu Shwe Oo, Cynthia Maung, Heather Kuiper, Nicole Mansenior, Chris Beyrer, and Thomas J. Lee (May 2008)The Mom Project: Delivering Maternal Health Services Among Internally Displaced Popula ons in Eastern Burma (May 2008). Reproduc ve Health Ma ers, Vol. 16, No. 31, pp. 44-56. h ps://ssrn.com/ abstract=1346880 L.K. Murray, S. Dorsey, E. Haroz, C. Lee, M.M. Alsiary, A. Haydary, … P. Bolton (2014). A Common Elements Treatment Approach for Adult Mental Health Problems in Low- and Middle-Income Countries, Cogni ve and Behavioral Prac ce, 21(2), pp. 111–123. h p://doi.org/10.1016/j.cbpra.2013.06.005 A.J. Nguyen, C. Lee, M. Schojan, P. Bolton (2018). Mental health interven ons in Myanmar: a review of the academic and gray literature, Global Mental Health, 5, e8, 1-12, doi:10.1017/gah.2017.30. Michael Paratharayil (2010), Basic versus focused psychosocial interven ons for community wellbeing: lessons following the Nargis cyclone interven ons in Burma/Myanmar, Interven on, 2010, Volume 8, Number 2, pp. 148–157. Leah Persky and Zaravshon Zukhurova, Health of Refugees and Internally Displaced Peoples, Review Digest: Human Rights & Health, pp. 130-142, h ps://www.du.edu/korbel/hrhw/researchdigest/health/refugees.pdf

ArƟ cles: “Year in Review: Public Health in Myanmar,” Elliot Brennan, Teacircleoxford, 21 May 2018, h ps://teacircleoxford. com/2018/05/21/year-in-review-public-health-in-myanmar/ “Medita ng on the Buddha in the midst of Buddhist Terror,” Richard Reoch, 9 May 2018, Lion’s Roar, h ps://www.lionsroar. com/221362-2/ “Of Health Care and Management Malprac ce,” Ye Min Zaw, The Irrawaddy, 18 April 2018, h ps://www.irrawaddy.com/ opinion/guest-column/health-care-management-malprac ce.html “A er the Massacre,” Andrew R.C. Marshall, 11 April 2018, Reuters, h ps://www.reuters.com/inves gates/special-report/ myanmar-massacre-survivors/ “The minister, errant monks and the Tatmadaw chief,” Sithu Aung Myint, Fron er, 1 April 2018, h ps://fron ermyanmar.

79 net/en/the-minister-errant-monks-and-the-tatmadaw-chief “Can a New President Pull Myanmar Out of the Quagmire of Confl ict?” Joe Kumbun, 29 March 2018, The Irrawaddy, h ps:// www.irrawaddy.com/opinion/guest-column/can-new-president-pull-myanmar-quagmire-confl ict.html “What Happens to Emergency Pa ents Transported to a Government Hospital in Myanmar?” 27 March 2018, h ps://www. emergency-live.com/en/news/happens-emergency-pa ents-transported-government-hospital-myanmar/ “Will Myanmar complete its transi on towards an evidence-based approach to drug control?” 20 March 2018, The Transna onal Ins tute, h ps://www.tni.org/en/ar cle/will-myanmar-complete-its-transi on-towards-an-evidence-based- approach-to-drug-control “In Myanmar, journalists have sided with the military against the Rohingya,” Joshua Carroll, 20 March 2018, Columbia Journalism Review, h ps://www.cjr.org/watchdog/myanmar-rohingya.php Statement by Mr. Marzuki Darusman, Chairperson of the Independent Interna onal Fact-Finding Mission on Myanmar, at the 37th session of the Human Rights Council, 12 March 2018, h p://www.ohchr.org/EN/HRBodies/HRC/Pages/NewsDetail. aspx?NewsID=22798&LangID=E “Women and drugs in Myanmar: Beyond harm reduc on,” 8 March 2018, The Transna onal Ins tute, h ps://www.tni.org/ en/ar cle/women-and-drugs-in-myanmar-beyond-harm-reduc on “Interna onal Community Fails to See Myanmar for What It Is,” Ye Min Zaw, The Irrawaddy, 15 February 2018, h ps://www. irrawaddy.com/opinion/guest-column/interna onal-community-fails-to-see-myanmar-for-what-it-is.html “Massacre in Myanmar: How Myanmar forces burned, looted and killed in a remote village,” Wa Lone, Kyaw Soe Oo, Simon Lewis and Antoni Slodkowski, 8 February 2018, Reuters, h ps://www.reuters.com/inves gates/special-report/myanmar- rakhine-events/ “Violence against women: a hidden public health crisis in Myanmar,” Aye Thiri Kyaw, Teacircleoxford, 5 February 2018, h ps://teacircleoxford.com/2018/02/05/violence-against-women-a-hidden-public-health-crisis-in-myanmar/ “End of Mission Statement by Special Rapporteur on the situa on of human rights in Myanmar,” Yanghee Lee, 1 February 2018, United Na ons Informa on Center Yangon, h p://yangon.sites.unicnetwork.org/2018/02/01/end-of-mission- statement-by-special-rapporteur-on-the-situa on-of-human-rights-in-myanmar-4/ “For Myanmar’s Army, Ethnic Bloodle ng Is Key to Power and Riches,” Richard Paddock, 27 January 2018, New York Times, h ps://www.ny mes.com/2018/01/27/world/asia/myanmar-military-ethnic-cleansing.html “This is Not Myanmar’s Path to Peace,” Fron er, 18 January 2018, h ps://fron ermyanmar.net/en/this-is-not-myanmars- path-to-peace “NLD government to face tougher challenges in 2018,” 5 January 2018, Shan Herald Agency for News, h p://english. panglong.org/2018/01/05/nld-government-to-face-tougher-challenges-in-2018/ “No shortage of Public Health Tests,” Myint Kay Thi, 29 December 2017, The Myanmar Times, h ps://www.mm mes.com/ news/no-shortage-public-health-tests.html “Myanmar: Peace Process Going Nowhere,” Dr. S. Chandrasekharan, 29 December 2017, Asia Analysis Group, Paper No. 6334, h p://www.southasiaanalysis.org/node/2246 “KIA Objects to Use of Vacant IDP Lands,” Nyein Nyein, 22 December 2017, The Irrawaddy, h ps://www.irrawaddy.com/ news/burma/kia-objects-use-vacant-idp-lands.html “While Rohingya Draw World A en on, Other Myanmar Refugees Face Crisis,” Michele Penna, 18 December 2017, Asia Sen nel, h ps://www.asiasen nel.com/society/other-myanmar-refugees-face-crisis/ “Burma and the Rohingya Crisis: We Can Oppose Ethnic Cleansing Without Accep ng Simple Answers,” Rosalie Metro, 15 December 2017, Tea Circle Oxford, h ps://teacircleoxford.com/2017/12/15/burma-and-the-rohingya-crisis-we-can- oppose-ethnic-cleansing-without-accep ng-simple-answers/ “2018 THE YEAR AHEAD: Achieving Peace And Resolving Armed Confl ict Would Remain Far-Fetched In Myanmar,” Sai Wansai, 15 December 2017, Shan Herald Agency for News, h p://english.panglong.org/2017/12/15/2018-the-year-ahead- achieving-peace-and-resolving-armed-confl ict-would-remain-far-fetched-in-myanmar/ “Myanmar s ll a serial landmine user,” monitor says, Jim Pollard, 15 December 2017, Asia Times, h p://www.a mes.com/ ar cle/myanmar-s ll-serial-landmine-user-monitor-says/?utm_source=The+Daily+Report&utm_campaign=b5a1572b35- EMAIL_CAMPAIGN_2017_12_15&utm_medium=email&utm_term=0_1f8bca137f-b5a1 “Rohingya refugee crisis: It’s not Muslims versus Buddhists, says writer Ber l Lintner,” Arunabh Saikia, 10 December 2017, Scroll.in, h ps://scroll.in/ar cle/860053/rohingya-refugee-crisis-its-not-muslims-versus-buddhists-says-writer-ber l- lintner “Myanmar’s Public Health System and Policy: Improving but Inequality S ll Looms Large,” Elliot Brennan, 1 September 2017, The Irrawaddy, h ps://www.irrawaddy.com/opinion/guest-column/myanmars-public-health-system-and-policy- improving-but-inequality-s ll-looms-large.html 80 “Myanmar’s Public Health system and policy: Improving but inequality s ll looms large,” Ellio Brennan, Teacircleoxford, 30 August 2017, h ps://teacircleoxford.com/2017/08/30/myanmars-public-health-system-and-policy-improving-but- inequality-s ll-looms-large-2/ “End of Mission Statement by Special Rapporteur on the situa on of human rights in Myanmar,” Yanghee Lee, 21 July 2017, United Na ons Human Rights, Offi ce of the High Commissioner, h p://www.ohchr.org/en/NewsEvents/Pages/DisplayNews. aspx?NewsID=21900&LangID=E “State Counsellor addresses the ceremony for Informing the Ini a on of Na onal Health Plan (2017-2021),” 1 April 2017, Global New Light of Myanmar, h p://www.globalnewlightofmyanmar.com/state-counsellor-addresses-the-ceremony-for- informing-the-ini a on-of-na onal-health-plan-2017-2021/ “K55 billion allocated for Na onal Health Plan,” Myint Kay Thi, 7 March 2017, Myanmar Times, h ps://www.mm mes.com/ na onal-news/25204-k55-billion-allocated-for-na onal-health-plan.html “Community Health: We Care for Our Own,” Health Convergence Core Group, 29 March 2016, Myanmar Times, h ps:// www.mm mes.com/opinion/19702-community-health-we-care-for-our-own.html “Racism in Burma,” Roland Watson, 2 February 2016, Dictatorwatch, h ps://www.burmalink.org/racism-burma/ “Sky crew: Harrowing plight of Rohingyas in Myanmar will stay with us,” Neville Lazarus and Alex Crawford, 27 November 2015, sky news, h ps://news.sky.com/story/sky-crew-harrowing-plight-of-rohingyas-in-myanmar-will-stay-with-us- 11123835 “Cholera Outbreak Kills 12 Karen Villagers,” Karen Informa on Center, Myanmar Peace Monitor, 26 October 2015, h ps:// www.bnionline.net/en/news/karen-state/item/1015-cholera-outbreak-kills-12-karen-villagers.html “Myanmar’s Na onwide Ceasefi re Agreement,” Backgrounder, October 2015, The Ins tute for Security and Development Policy, www.ISDP.EU “Border-Based Groups Come Together to Help Burma’s Flood Vic ms,” 7 August 2015, h ps://www.bnionline.net/en/news/ karen-state/item/661-border-based-group-come-together-to-help-myanmar-s-fl ood-vic ms.html “A Poli cian, Not an Icon: Aung San Suu Kyi's Silence on Myanmar's Muslim Rohingya,” Ronan Lee (2014), Islam and Chris an–Muslim Rela ons, h p://dx.doi.org/10.1080/09596410.2014.913850 “Karen Soldier Killed in Latest Figh ng, KNU Claims Government Troops A acked First,” Karen News, 30 September 2014, h p://karennews.org/2014/09/karen-soldier-killed-in-latest-fi gh ng-knu-claims-government-troops-a acked-fi rst/ “Back Pack Jungle Medics Trea ng IDPs in Burma’s Confl ict Zones: Interview with Saw Win Kyaw,” 20 March 2014, BurmaLink, h p://www.burmalink.org/story-jungle-medic-ethnic-health-director-saw-win-kyaw/ “Separa ng Fact from Fic on about Myanmar’s Rohingya,” Gregory Poling, 13 February 2014, Center for Strategic and Interna onal Studies, h ps://www.csis.org/analysis/separa ng-fact-fi c on-about-myanmar’s-rohingya “The Impact Of Doctors Per Capita On The Mortality Rate In Asia,” Anil She y and Shraddha She y (2014), Interna onal Journal of Medical and Pharmaceu cal Sciences, h ps://www.researchgate.net/publica on/279186850_THE_IMPACT_ OF_DOCTORS_PER_CAPITA_ON_THE_MORTALITY_RATE_IN_ASIA “State Govt and CBO’s Agree to Help Confl ict-Aff ected Karen Communi es,” Saw Tun Lin, Karen News, 31 May 2013, h p:// karennews.org/2013/05/state-govt-and-cbos-agree-to-help-confl ict-aff ected-karen-communi es/ “Wages of Burman-ness:” Ethnicity and Burman Privilege in Contemporary Myanmar,” Ma hew J. Walton, 19 October 2012, Journal of Contemporary Asia, Vol. 43, 2013, h ps://www.tandfonline.com/doi/abs/10.1080/00472336.2012.730892 “Bi er Wounds and Lost Dreams: Human Rights Under Assault in Karen State, Burma,” Adam Richards, M.D, PhD, MPH, Physicians for Human Rights, August 2012, h p://physiciansforhumanrights.org/library/reports/bi er-wounds-and-lost- dreams.html “Death Stalks Pregnant Women In East Myanmar,” Marwaan Macan-Markar, 17 July 2012, h ps://womanistheniggero heworld. wordpress.com/2012/07/17/death-stalks-pregnant-women-in-east-myanmar/ “The Road Up From Mandalay,” Lashio, 21 April 2012, The Economist, h ps://www.economist.com/node/21553091 “Burma Army Arrests Health Workers,” Nan Thoo Lei (KIC), Karen News, 10 November 2011, h ps://bphwt.wordpress. com/2011/11/11/burma-army-arrest-health-workers/ “Karens Flee Figh ng in Burma, But Live in Limbo in Thailand,” Danielle Bernstein, 15 March 2011, VOA News, h ps://www. voanews.com/a/karens-fl ee-fi gh ng-in-burma-but-live-in-limbo-in-thailand-118072334/167199.html “Thousands S ll Displaced Along Border,” 25 January 2011, IRIN News, h p://www.irinnews.org/report/91724/thailand- myanmar-thousands-s ll-displaced-along-border “In eastern Burma confl ict, medics face the same dangers as those they treat,” Alisa Tang, 25 January 2011, The Guardian, h ps://www.theguardian.com/world/2011/jan/25/thailand-burma-confl ict-medic-tang “Burmese junta rigged vote through advanced vo ng,” Tint Swe, 11 November 2010, AsiaNews.it, h p://www.asianews.it/ 81 news-en/Burmese-junta-rigged-vote-through-advanced-vo ng-19961.html “Health Crisis Amid Confl ict - New Report,” IRIN News, 19 October 2010, h p://www.irinnews.org/news/2010/10/19/ health-crisis-amid-confl ict-new-report “Flu Outbreak in Papun District,” 25 November 2009, h p://backpackteam.org/wp-content/uploads/2014/07/Flu- statement_251109.pdf “An Overview of Burma’s Ethnic Poli cs,” Chris na Fink, Cultural Survival Quarterly Magazine, September 2000. Movies and Videos: Backpack Health workers in Burma, h ps://www.youtube.com/watch?v=FrhWxvfddEA Diffi cult to Stay, Diffi cult to Go Home, about refugees living along Thai-Burma border, h ps://vimeo.com/246384874?ref= - share Facing Burma, Finding Thailand, h ps://m.youtube.com/watch?v=kg05s6W5HiY Live Like we Don’t Exist, h ps://vimeo.com/260495758 Heart of Darkness, BPHWT produced short video, h ps://m.youtube.com/watch?v=l0swNoQtkYQ Into the Current: Burma’s Poli cal Prisoners, h ps://freelibrary.kanopystreaming.com/video/current-burmas-poli cal- prisoners Myanmar’s Killing Fields, Frontline, May 2018, h ps://www.pbs.org/wgbh/frontline/ Recognize Us: Refugee Youth on the Thai-Burma Border, Burma Link, Karen Student Network Group and Karen Youth Organiza on, May 2017, h ps://www.burmalink.org/recognise-us-refugee-youth-thailand-burma-border/ Saw O Moo: Defender of Indigenous Karen Territories, the Environment and Way of Life, karennews.org, May 2018, h ps:// vimeo.com/268211645 The Black Zone, 42 min documentary, follows a BPHWT medic The Jungle Surgeon of Myanmar, Gigi Berardi, 15 January 2016, aljazerra.com, h ps://www.aljazeera.com/programmes/ witness/2014/01/jungle-surgeon-myanmar-201411281327432341.html The Nightmare Returns: Karen hopes for peace and stability dashed by Burma Army’s ac ons, Karen Peace Support Network, April 2018, h ps://www.facebook.com/KPSN.karen/videos/2078417609101836/?fref=men ons Today I Rise, h p://www.fi lmsforac on.org/watch/today-i-rise/ Video created by Burma Humanitarian Mission for Dining for Women event, h ps://diningforwomen.org/programs/burma- humanitarian-mission/

Websites: Back Pack Health Worker Team: h p://backpackteam.org/ Burma Link: h ps://www.burmalink.org Burma Humanitarian Mission: h p://burmamission.org/ Burma Relief Center: h ps://interpares.ca/content/burma-relief-centre-brc Free Burma Rangers: h p://www.freeburmarangers.org Progressive Voice Myanmar: h ps://progressivevoicemyanmar.org Mae Tao Clinic: h p://maetaoclinic.org Oxford Burma Alliance: h p://www.oxfordburmaalliance.org/learn-about-burma.html Karen Department of Health and Welfare: h ps://kdhw.org Shan State Development Founda on: h ps://www.facebook.com/shandevelopment/ HISWG website: h p://hiswg.org/ The Border Consor um: h p://www.theborderconsor um.org/what-we-do/partners/ Karenni Social Development Center: h p://karennisdc.org/karenni-state/ Online Burma Library: h p://burmalibrary.org

82 e,fvSnfhausmydk;tdwf usef;rma&;vkyfom;tzGJU Back Pack Health Worker Team P.O Box 57, Mae Sot, Tak 63110, Thailand ph/fax: 055545421, email: [email protected] www.backpackteam.org

toto BuildBuild SustainableSustainable PrimaryPrimary HealthHealth CareCare forfor Burma’sB ’ DDisplacedi l d andd VulnerableV l bl EthnicE h i Communi es

87 The role of health workers is much more than doing medical things. They need to rebuild the community as well…learn to work together, nego ate, build trust and empower the people. We want the young people to feel that they are the people who can make change. They are the people who can mobilize their community to know basic health rights. We especially hope the younger genera on will get involved — as leaders. Dr. Cynthia Maung, From Rice Cooker to Autoclave

e,fvSnfhausmydk;tdwf usef;rma&;vkyfom;tzGJU Back Pack Health Worker Team P.O Box 57, Mae Sot, Tak 63110, Thailand ph/fax: 055545421, email: [email protected] www.backpackteam.org

86