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Militarization, Risk and Community Responses

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Health and Human Rights in Post-Conflict Eastern Burma: Militarization, Risk and Community Responses by William W. Davis, MA, MPH A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Public Health Baltimore, Maryland January, 2014 © 2014 William W. Davis All rights reserved Executive Summary Background Despite recent political reforms in Burma, human rights abuses are ongoing in ethnic regions in the country. Fighting continues in some areas, and ceasefires in others have not brought an end to human rights violations. In response to political reforms, the international community has decreased political and financial support for ethnic communities in Burma, leaving them more vulnerable than ever. Continued advocacy for an end to human rights abuses and for continued humanitarian support for ethnic groups in Burma is greatly needed. The goals of this project were to gather evidence of human rights abuses in Karen state, eastern Burma, identify health consequences of these abuses and use the data to advocate for justice for victims. Methods We created a framework to describe social determinants of health in Karen state and used it to generate hypotheses about the effects of militarization and human rights violations on health and the role of village responses in moderating these effects. A second framework was used to operationalize international human rights law into a survey instrument applicable in Karen state. We then conducted a systematic literature review to determine state-of-the-art methods for cluster sampling in conflict areas and to identify cases in the peer-reviewed literature when security precautions may preclude following best practices for sampling. Using the best practices identified by the literature review, we conducted a two-stage cluster survey of 686 households in eastern Burma in January 2012 that covered health status, access to healthcare, food security, exposure to human rights violations and identification of perpetrators. ii Data analysis included descriptive and interpretive components. We used logistic regression to identify associations between exposure to armed groups, village responses, human rights abuses and health outcomes. Results This project provided timely data that documented human rights abuses in Karen state and the need for humanitarian assistance. Data was used to advocate for continued humanitarian aid for ethnic areas, continued pressure on the Burmese government to stop human rights abuses and for perpetrators of human rights abuses to be held accountable for their crimes. Household hunger, measured by FANTA-2 scale, was low in 581 (84.7%) households, moderate in 85 (12.3%) households and high in six (0.9%) households. Households reporting food shortages during any month in 2011 ranged from 19.9% to 47.0%, with food insecurity peaking just prior to the harvest. Diarrhea prevalence in children was 14.2% and night blindness in women of child-bearing age was 5.6%. Forced labor was the most common human rights violation, reported by 185 households (24.9%); 210 households (30.6%) reported experiencing at least one human rights violation in 2011. Multiple logistic regression analysis identified associations between human rights violations and poor health outcomes. Novel Findings This is the first study to assess the latest methods for cluster sampling in conflict areas. We found that researchers doing cluster surveys in conflict areas must sometimes alter methods to ensure safety and security of field surveyors. Common alterations are skipping and replacing iii clusters that are insecure, making fewer attempts to revisit empty households, using fewer field supervisors and making contextual decisions on how best to allocate households to clusters. Several common security protocols are identified. This is also the first study to examine militarization and village responses in Burma. Close proximity to a military base was a predictor of human rights violations, inadequate food production, inability to access healthcare and diarrhea. Exposure to armed groups predicted these outcomes and also household hunger. In households that reported no human rights violations, risk of household hunger, inadequate food production, diarrhea and child diarrhea increased when neighbors’ households reported human rights violations. Households in villages that reported using any self-protection technique had lower risk of experiencing human rights violations. Households in villages that reported negotiating with the Burmese army had lower risk of human rights violations, household hunger, inadequate food production and diarrhea. Stratified analysis suggests that self-protection may modify the effect of exposure to armed groups on risk of human rights violations and some health outcomes. iv Acknowledgements I have been fortunate in my doctoral experience to have worked with so many intelligent and inspiring people. The team at Physicians for Human Rights showed me the value of a strong dedication to the mission and vision of an organization. My supervisor Rick Sollom trusted me to work independently in the field and encouraged me to develop new projects and examine new angles of human rights and health in the region. Andrea Gittleman and Hans Hogrefe taught me everything I know about advocacy. I have never worked with a more open and collaborative team. Vince Iacopino and Adam Richards gave me new insights into approaching research design. I spent a year in Mae Sot, Thailand, planning and implementing this project. There I developed lasting friendships and working relationships. Collaborating with the partner organizations reinforced the deep respect that I developed long ago for community-based organizations. I am grateful to BPHWT, KDHW, CIDKP, KYO and the anonymous partner for collaborating with PHR despite tremendous workloads. I learned a lot from our partners. Eh Kalu’ friendship, Mahn Mahn’s candor, Win Kyaw’s dedication and Tah Doh Moo’s experience were all invaluable assets to me. The surveyor training was successful because of the work of Htu Htike San as training coordinator. Jen Leigh (of GHAP) and Cate Lee helped me settle into Mae Sot and introduce me to potential partner organizations. They, along with Charlene, Sam, Tatyana and Myo gave moral support. Matt Finch and Khu Khu Ju of KHRG gave excellent updated advice on the situation in Karen state and taught me about village agency. The people at FBR graciously shared their experience inside Karen state with me and helped me to understand what it was like to live v there. Thanks to Matt Smith and the rest of the human rights people on the border for their open sharing of information. I am glad to have befriended Vit Suwanvanichkij, a master of all things related to public health and politics in Burma and on the border. Finally, I am grateful for the 22 men and women on the survey team who took two months out of their schedule to train and then implement the survey. Because of them this work was possible. My colleagues and advisers at JHSPH helped me to grow as a scientist and public health advocate. My advisor Chris Beyrer is responsible for the collaboration between PHR and his Center for Public Health and Human Rights at Hopkins. Chris taught me that advocacy and science are inseparable and that we always have to push for justice. Luke Mullany mentored me as a scientist and researcher. Bob Lawrence inspired me early on in my academic career to pursue health and human rights. Candid advice about everything Hopkins from Jim Tielsch helped me to navigate through years of grad school. Stef also gave similar advice. Sos K and the Hopkins biostats clinic helped me through the data analysis. Andrea and Emily guided me through the IRB process. Thanks to Sarah for building the Access database and to Hannah for helping with the literature review. I am especially grateful for the team--my DrPH cohort and our PhD friends--for helping me to maintain the balance between working hard and having fun. My family’s love and support got me through the difficult stages of the research and of the doctoral program. Long ago I learned from them that anything can be accomplished with hard work and a good sense of humor. Thanks to Beth, Abby, Alma, Dick, Phoebe, Stella and especially Ah Noh. vi Table of Contents Executive Summary .......................................................................................................................... ii Acknowledgements.......................................................................................................................... v Table of Contents ............................................................................................................................ vii List of Tables .................................................................................................................................. viii List of Figures ...................................................................................................................................ix Abbreviations ................................................................................................................................... x Project Overview .............................................................................................................................. 1 Problem Statement ...................................................................................................................... 1 Specific Aims of the Dissertation: ...............................................................................................
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