From Rice Cooker to Autoclave at Dr. Cynthia's

From Rice Cooker to Autoclave at Dr. Cynthia’s MAE TAO CLINIC From Rice Cooker to Autoclave at Dr. Cynthia’s Mae Tao Clinic: Twenty Years of Health, Human Rights and Community Development in the Midst of War

Written and published by Mae Tao Clinic February 2010

Front cover photo: Dr. Cynthia with a Mobile Medical Team in Dooplaya district treating a child, 1994. [photo: MTC]

The Mae Tao Clinic (MTC), founded and directed by Dr. Cynthia Maung, provides free health care for refugees, migrant workers, and other individuals who cross the border from Burma to Thailand. People of all eth- nicities and religions are welcome at the clinic.

Visit: www.maetaoclinic.org

This book published by MTC. All rights reserved. Con- tent may be quoted for media and related purposes, but reproduction for commercial purposes requires the prior permission of MTC. TABLE OF CONTENTS

Acknowledgments ...... ii List of Abbreviations ...... iv Letter from Dr. Cynthia maung ...... 1 Lessons Learned ...... 2 Mae Tao Clinic: The Story ...... 3 Thailand - Burma Border Situation ...... 9 Clinic Staff ...... 11 A Community of Organizations ...... 12 1989 – 1994: The beginning ...... 13 a) Referral Program ...... 14 b) Dressing, Surgery, and Trauma ...... 16 c) Reproductive Health ...... 19 d) Food & Nutrition Program ...... 21 e) Mobile Medical Teams ...... 22 f) Civil Clinics ...... 24 i) Cho Gali Clinic: ...... 24 ii) Sa Khan Thit: ...... 25 iii) Pa Hite: ...... 25 a) Medical Outpatient Department ...... 26 b) Laboratory and Blood Bank ...... 28 i) Blood Donation Center ...... 29 a) Water and Sanitation...... 30 b) Partnerships: 1989 - 1994 ...... 31 i) Planet Care/Global Health Access Program ...... 31 ii) Burmese Relief Center ...... 32 iii) Brackett Refugee Education Fund ...... 33 iv) All Burma Students Democratic Front ...... 33 v) Karen Department of Health and Welfare ...... 33 vi) Burma Medical Association ...... 34 vii) Mae Sot Hospital ...... 35 1995 – 1999: Getting Organized ...... 39 a) “A Land of War: A Journey of the Heart” ...... 40 b) Child Protection Services ...... 42 i) Delivery Certiﬁ cates and Child Documentation ...... 44 ii) Bamboo Children’s Home ...... 44 iii) The Children’s Development Center ...... 45 iv) Emergency Dry Food Program ...... 46 a) Eye Clinic ...... 47 b) Training Programs ...... 49 c) Child Outpatient Department ...... 51 d) Clinic Library ...... 52

FROM RICE COOKER TO AUTOCLAVE | 3 e) Medical & Child Inpatient Department ...... 53 f) Finance & Administration ...... 55 g) Stability and Security for Mae Tao Clinic ...... 57 h) Partnerships: 1995 - 1999 ...... 58 i) Back Pack Health Worker Team ...... 58 ii) Karen Women’s Organisation (KWO) ...... 59 iii) Karenni Nationalities Health Worker Organization ...... 59 iv) Shan Health Committee ...... 59 2000 – 2004: Building Capacity ...... 61 a) Healer of broken souls ...... 62 b) One refugee can change the world ...... 63 c) Prosthetics Department ...... 64 d) Health Information Systems ...... 66 e) Registration / Medical Records Department ...... 67 f) HIV Story ...... 68 g) School Health Program ...... 71 h) Public Relations ...... 73 i) Dental Clinic ...... 75 j) Partnerships: 2000 - 2004 ...... 77 i) Burmese Migrant Workers Education Committee (BMWEC) ...... 77 ii) Committee for the Protection and Promotion of Child Rights ...... 77 iii) Adolescent Reproductive Health Network ...... 77 iv) Human Rights Education Institute of Burma ...... 78 v) Social Action for Women ...... 78 vi) Burma Children Medical Fund ...... 78 2005 – 2009: The Scope Broadens ...... 80 a) Refugee Doctor ‘Making a Difference’ for Thousands in Burma ...... 81 b) For Choo, it's all work and no play ...... 82 c) Counselling Centre ...... 85 d) Research ...... 86 e) Infection Prevention Unit ...... 88 f) Pharmacy ...... 89 g) Partnerships: 2005 - 2009 ...... 91 i) International Partnerships ...... 91 ii) Local Collaboration Continues to Grow ...... 91 Dr. Cynthia’s Thoughts: Looking to the future ...... 92 Donors ...... 93 Awards ...... 95 a) Resources ...... 100 Book Contributors ...... 102

FROM RICE COOKER TO AUTOCLAVE | i ACKNOWLEDGMENTS

Mae Tao Clinic presents this book about our 20-year history as a gift to our supporters, donors, and community. The intention of this book is to honor those contributions and support with which the success of the clinic today would not have been possible.

There are many donors, supporters, volunteers, partners, organizations and individuals who may not have been speciﬁ - cally mentioned. We take this opportunity to recognize and appreciate all of your efforts and support over the years.

The text of the book was compiled from the oral history of the clinic as related by clinic staff and by Dr. Cynthia Maung. If it contains any inaccuracies or omissions, it is surely the fault of the editors. If you feel something is incorrect or incomplete, we welcome your stories and facts which will help us to ﬁ ll out the history of the clinic for future website updates.

Our ﬁ rst priority was to hear the voice of the clinic staff and Dr. Cynthia Maung, and to reﬂ ect that to you, the reader. We thank the Mae Tao Clinic staff who took time out from their daily workload to relate stories and facts for the book. Finally, we thank Dr. Cynthia Maung for patiently relating stories and facts from the past. She did this during the quiet hours of the early morning before the Clinic’s day began and during holidays when she could afford the extra hours. We were fortunate that Dr. Cynthia’s memory appears to be as strong as it was 20 years ago when the clinic began.

ii | FROM RICE COOKER TO AUTOCLAVE

“We will surely get to our destination if we join hands.”

Aung San Suu Kyi

FROM RICE COOKER TO AUTOCLAVE | iii LIST OF ABBREVIATIONS

ABSDF All Burma Students Democratic Front AIDS Acquired Immunodeﬁ ciency Syndrome ANC Antenatal Care ARHN Adolescent Reproductive Health Network ARV Anti Retroviral Treatment BBG Burma Border Guidelines BCH Bamboo Children’s Home BAMF Burma Adult Medical Fund BCMF Burma Children Medical Fund BMA Burma Medical Association BMWEC Burmese Migrant Workers Education Committee BPHWT Backpack Health Worker Team CBOs Community Based Organizations CDC Children’s Development Centre CHW Community Health Worker CMH Chiang Mai Hospital CPPCR Committee for the Protection and Promotion of Child Rights CTDCE Coordination Team for Displaced Children’s Education DKBA Democratic Karen Buddhist Army FHI Family Health International GHAP Global Health Access Program HBC Home-Based Care Program (for HIV) HIV Human Immunodeﬁ ciency Virus HIS Health Information Systems ICRC International Committee of the Red Cross IDPs Internally Displaced Persons INGOs International Non-Governmental Organizations IPD Inpatient Department IPU Infection Prevention Unit IRC International Rescue Committee KAP Knowledge and Practices Survey KNU Karen National Union KWO Karen Women’s Organization KYO Karen Youth Organization KHWA Karenni Health Worker Association MAP Migrant Assistance Program MMT Mobile Medical Teams

iv | FROM RICE COOKER TO AUTOCLAVE MOE (Thai) Ministry of Education MOH (Thai) Ministry of Health MSF Médecins Sans Frontières MSH Mae Sot Hospital MTC Mae Tao Clinic NGOs Non-Governmental Organizations NHEC National Health and Education Committee NLD National League for Democracy OPD Outpatient Department PHC Primary Health Care (training) PHPT Perinatal HIV Prevention Trial PMTCT Preventing Mother to Child Transmission (of HIV) PRC Public Relations Center RH Reproductive Health Department SAW Social Action for Women SHC Shan Health Committee SLORC State Law and Order Restoration Council SMRU Shoklo Malaria Research Unit SPDC State Peace and Development Council STIs Sexually Transmitted Infections TB Tuberculosis TBA Traditional Birth Attendants TBBC Thai Burma Border Consortium TDH Terre Des Hommes VCT Voluntary Counselling and Testing (for HIV and STIs) WEAVE Women’s Education for Advancement and Empowerment

FROM RICE COOKER TO AUTOCLAVE | v vi | FROM RICE COOKER TO AUTOCLAVE LETTER FROM DR. CYNTHIA MAUNG

THE ROLE OF HEALTH workers is much more than doing medical things. They need to rebuild the community as well…learn to work together, negotiate, 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 generation will get involved – as leaders.

When I look at the clinic, I see people working very hard. Sometimes, there’s a lot of pressure both psychologically and ﬁ nancially. Staff have been away from their family for many years, and they always hope to go back home. The people we serve have the same feelings. I think everybody has sad feelings: When can we go back to our homeland?

But the problems in Burma cannot be solved quickly. Even if the SPDC collapses or the political opposition wins the election, the country is still traumatized by landmines, prostitution, street children, broken families. People have lost their dignity and identity. Health services and education are not accessible to the people. All this cannot be ﬁ xed within a few years.

So we will expand as long as we need to provide health services for people from Burma. Wherever and whenever there are poor people in the community, we will continue to serve.

We at the Mae Tao Clinic invite you to join us in providing health care and building the community on the Thai-Burma border or wherever there is a need in the world. We hope you feel empowered by the clinic’s successes, rather than impressed or overwhelmed. We want you to understand that you, too, can take on such projects. The key is to start small and grow.

We leave you with lessons we’ve learned over the past 20 years in hopes that our shared experiences may be helpful as you go forward to serve.

Dr. Cynthia Maung and the Founders of the Mae Tao Clinic

FROM RICE COOKER TO AUTOCLAVE | 1 LESSONS LEARNED

1. No matter how bad the situation, you can always ﬁ nd ways to make it better. First, identify existing resources. Start with the people already working as community-resource providers - teachers, religious leaders, village heads, midwives, medics, grand- mothers - or the neighbor everyone looks to for help and advice. Take time to listen, show respect, and learn from their experiences. Work with them to identify needs and plan solutions using existing resources.

2. Try to understand rather than to judge. If you judge people’s beliefs or practices, it’s harder to work as partners. For example, don’t fault a family for refusing to boil their drinking water if they only have one pot and it’s needed for cooking. Instead, try to provide another pot or ﬁ nd a more appropriate method for purifying their water. Under- stand people’s resources, emotions, and culture before you try to change their behav- ior.

3. You can’t improve the health of the people without improving their community. Use a comprehensive, sustainable approach: nutrition, sanitation, clean water, medical care, and education. If people understand health and human rights, they’ll have the keys to building a healthy stable community. Then, if those rights are ever taken away, they’ll work to get them back. If the people aren’t educated, if they don’t have jobs, if they’re depressed - they won’t be able to care for themselves or their children. They will starve, get sick, and have accidents. Some daughters will enter brothels and some sons will join the army. They will have no choice.

4. Train and use local people to work in their own community whenever possible instead of bringing in outsiders to provide services. Locals have a better understanding of a given political and social situation, geography and culture, and can move around more easily and safely. And since they’re from the area, they’re more likely to stay and network with other local leaders to improve the community.

5. Wherever you go or whatever you do, reach out. Don’t isolate yourself. Learn the language and culture of your neighbors and host country. Work together with humble farmers, university professors, large NGOs, small community-based organizations. “Community is not based on ethnicity or country of origin,” Dr. Cynthia says. “It’s based on human rights, human dignity and security.”

6. Rise above rumors, suspicion and fear. These are the regime’s most powerful weap- ons. They turn people against each other, erode the community, and destroy the heart.

7. Don’t give up, even when things get really bad. “You can look back over your shoulder, and then they win,” Dr. Cynthia says, “Or you can look forward, and you win.”

2 | FROM RICE COOKER TO AUTOCLAVE MTC founders in 1989 MAE TAO CLINIC: THE STORY

IN FEBRUARY 1989, fi ve idealistically hoping international pres- clinic now shoulders an annual casel- months after fl eeing a brutal military sure would force the junta into peace oad of about 90,000 patients; somehow crackdown in Burma, Dr. Cynthia negotiations with pro-democracy squeezes as many as 200 patients on its Maung and a small group of students groups and ethnic minorities. “We 150 beds; runs a jungle fi eld clinic; and opened a makeshift medical clinic in a didn’t expect to be here 20 years,” Dr. feeds 2,000 school children, patients, rickety wooden house on the dusty out- Cynthia says. While the fl edgling group staff and their families every day. Cur- skirts of Mae Sot, Thailand. In the be- was establishing what was to become rently, just over half of the clinic’s pa- ginning, the clinic had virtually no sup- the Mae Tao clinic in Mae Sot, inside tients are from the local Burmese mi- plies, no money, and (except for Dr. Myanmar the civil confl ict worsened grant community, with the rest traveling Cynthia) no staff formally trained in and the military dictatorship tightened from inside Burma to seek healthcare. medicine. Other factors compounded its grip over the country. So instead of The clinic’s health services have their problems; they were in Thailand returning to reform their homeland, the to cope with both acute and chronic illegally, and didn’t speak the lan- group continued to work at the humble medical problems. Staff members treat guage. clinic with limited available resources, everything from minor maladies to ma- All of the clinic’s medical instru- using medicine, education, and out- laria, tuberculosis (TB), HIV/AIDS, ments fi t into the woven bag that Dr. reach to relieve human suffering and malnutrition, pneumonia, acute diar- Cynthia had slung over her shoulder heal broken communities. rheal diseases, diabetes, epilepsy, thy- during the ten-night trek to escape TWO DECADES LATER, the roid disease, cancer and mental illness. through the jungle of Burma’s eastern Mae Tao Clinic (MTC) has grown into The surgical department repairs herni- border region. There was a stetho- a comprehensive community health as, drains abscesses, performs vasecto- scope, a pair of scissors, two pairs of center and a hub for regional health- mies and treats minor wounds, burns forceps, a thermometer, a blood pres- training with more than 1,000 gradu- and injuries. The reproductive health sure cuff, one medical textbook, and a ates serving clinics, schools, villages, department pr ovides family planning, few packets of basic medications. With factories, camps and peri-urban slums antenatal care, normal (and some com- these limited tools and a commitment along both sides of the Thai-Burma plicated) labor and delivery, neonatal to care for all who fl ed war and oppres- border. In some remote areas inside care, post abortion care and gyneco- sion in Burma, the Mae Tao Clinic was Myanmar, the clinic’s former students logical services. born. have become the only sources of medi- The clinic’s eye program provides The clinic’s young founders an- cal care. vision screening, corrective lenses and ticipated returning to Burma within With an estimated 2009 budget of cataract surgery. A dental program months of their arrival on the border, 99,413,550 baht (US$2.9 million), the handles fi llings, root canals and extrac-

FROM RICE COOKER TO AUTOCLAVE | 3 tions. Its prosthetics program fabri- dren; counselling and home-based bag. cates and fi ts artifi cial legs, teaches treatment for HIV/AIDS patients; a IN THE BEGINNING, there was patients to walk on their new limbs and mobile medic program to train and no blueprint for the Mae Tao Clinic, no trains survivors for jobs in prosthetics equip health workers in war torn areas comprehensive plan. Instead, the clin- and other vocations. of Burma and an education and advo- ic evolved as Dr. Cynthia and the stu- MTC’s pediatrics department cacy program to protect thousands of dents learned and responded to the cares for children with acute and children (many without parents) from needs of the communities and individ- chronic illnesses; provides routine im- malnutrition, child traffi cking and la- uals around them. The founding mem- munizations, screens for malnutrition, bor exploitation. bers of the clinic comprised a group of and distributes de-worming medica- The clinic also provides emer- 14 people who fl ed to the Thai-Burma tion, Vitamin A, and supplementary gency food, shelter and medical care in border in September 1988, traveling food. MTC also runs thriving health the wake of crises such as Cyclone mostly at night to hide from the Bur- and dental program for 58 migrant Nargis, the Saffron Revolution and re- mese army, walking single-fi le to avoid schools; and operates a school in Mae lentless military attacks in eastern Bur- stepping on landmines. Naw Htoo, Sot for over 1,000 students (including ma. now a leader in the reproductive health 440 boarders) as well as a Bamboo In recognition of the clinic’s role department recalls, “I was 20. I had Children’s Home boarding house in in alleviating human suffering, Dr. never been in the jungle before, we Umpium Mai Refugee Camp for 154 Cynthia and the Mae Tao Clinic have were very afraid.”

View of old clinic building unaccompanied minors. been honored with many international During their escape to the Thai- The clinic’s support services in- humanitarian awards, and Dr. Cynthia Burma border, the group passed clude a lab that processes thousands of has been nominated for the Nobel through many poor villages in ethnic malaria smears each year and conducts Peace Prize (see Annex: Awards). areas where people had no access to rapid HIV testing; a rigorous infection MTC represents a model for commu- medical care. When villagers heard control team; a central pharmacy; a nity-based health care, and as such it Dr. Cynthia was a physician, they health information team that manages has received many visits from health asked for her help in treating illnesses the clinic’s registration, patient records, and human rights leaders who have and injuries and the young doctor did integrated database and fi nancial sys- shared their support and experiences. what she could with what little she had tems; a community relations team that Last year, the clinic hosted a delegation at that time. Many of the original 14 provides around-the-clock social sup- of Nobel Peace laureates and the then joined other student or Karen groups port for patients and their families, U.S. First Lady Laura Bush. along the way, leaving just three of the helps locate missing people, arranges Today, surveying the clinic’s ar- original group. Three other people funerals, and responds to the needs of ray of accomplishments and its sprawl joined this small band along the way in those escaping from brothels and im- of simple, sturdy concrete buildings, it the course of the journey, resulting in migration raids. is remarkable to think that the clinic the six founders of Mae Tao Clinic. MTC has set up safe houses for started with just a few medical instru- Witnessing the villagers’ enor- abused women and abandoned chil- ments stuffed into a woven shoulder mous suffering and fear of the military 4 | FROM RICE COOKER TO AUTOCLAVE made a powerful impression on the opposition groups eventually began to along the border, assessing the health- fl eeing students. Initially, many Bur- cooperate and, for the most part, trust care situation and distributing donated man students distrusted the Karen peo- each other. paracetamol and quinine for malaria. ples, a side-effect of a youth spent ab- From the chaos and instability of Later, Dr Cynthia cared for malaria pa- sorbing the military’s propaganda these early years emerged the key- tients in the home of a Karen leader, about “ethnic insurgents.” Such is the stones that would guide the clinic for but the house could not accommodate power of the military’s propaganda the next two decades: Dialogue. Coop- the numbers and soon became over- machine that these young students eration. Generosity. Trust. Training. crowded. were not then aware that the junta had When she fi rst arrived in Thai- In February 1989, a Karen family torched, displaced and abused thou- land, Dr. Cynthia and her friends offered Dr Cynthia and her associates a sands in ethnic areas, a situation that stopped at Mae La1 opposite Beh Klaw dilapidated wooden stilt-house on the continues today. The villagers in the refugee camp in the Tha Song Yang outskirts of Mae Sot as a possible loca- ethnic rural areas were likewise wary district. Here Dr. Cynthia worked at a tion for treating patients. Dr. Cynthia of the students; due to their isolation small hospital treating those fl eeing the and fi ve students moved into the run they hadn’t heard of the democracy down building. Sein Hein, one of the movement or the turmoil that had re- 1 Mae La is also known as ‘Beh Klaw’ in Kar- founders, recalls, “When we arrived at cently shaken the capital. en, which means ‘cotton fi eld’ due to the agricul- the new place for cleaning, I was really tural activities for which Karen leaders fi rst ne- “On the border, for the fi rst time, gotiated permission for refugees to cross into the in despair, seeing the old building al- area in 1984.

Dr. Cynthia Maung and family (photo: Tom Reese @ Seattle Times) the democratic movement and the eth- fi ghting. Diseases were rampant: diar- most falling down in decay with a lot nic revolution met,” Dr. Cynthia says. rhea, pneumonia and malaria among of spider webs, dirty with charcoal and The ethnic groups talked of autonomy; them. In addition to the dangers of a surrounded by bush forest.” Naw the students spoke of democracy and life on the run in jungles, many were Htoo, another member of the original human rights. The arrival of democra- affl icted by homesickness and a long- group, remembers, “We had nothing! cy advocates in the traditionally ethnic ing for loved ones who were left be- No mosquito net, no blanket, no food! strongholds of eastern Burma foment- hind in the disorganized fl ight. Some I said: Give me 5,000 baht! And I went ed a political awakening for both stu- tried to return to Myanmar; others de- out and bought 20 pillows and blan- dents and civilians, as well as those cided to stay. kets” and other basics with which the seeking greater autonomy and rights After a month or so, Dr. Cynthia’s group set up their clinic. for the ethnic regions. The two groups’ group moved to Hway Ka Loke refu- The fi rst two years were driven widely disparate political aims howev- gee camp and there they made contact by a motivation to help fellow refugees er, initially created distrust. There was with Karen leaders responsible for stu- and was made possible by the creative also massive confusion in the aftermath dent affairs and with local Thai author- ability to adapt and optimize limited of the crushed revolution as thousands ities and church groups who were sym- resources. The group cared for students of people tried to fi nd their friends and pathetic to the people’s plight. recovering from severe malaria, deliv- families, fl ee the cities and organize re- Together, they tried to organize, priori- ered food to those who were hospital- sistance groups. Despite the chaos re- tize and organize treatment for patients. ized, and nursed them back to health sulting from the military crackdown, Dr. Cynthia visited fi ve student camps after they had been treated. The group

FROM RICE COOKER TO AUTOCLAVE | 5 solicited medicine and food from Cath- mine injuries. The clinic was still these tests. Most would never be able olic relief workers and other donors. functioning without a microscope, so to afford these tests in Thai or Burmese patients with symptoms of fever, chills At this time the group lacked an auto- hospitals. clave, so Dr. Cynthia improvised by and severe shaking chills (rigor) were When MTC fi rst began antenatal sterilizing her few precious instruments presumed to have malaria unless the screening, the HIV prevalence among in a rice cooker, an innovation inspired medics could fi nd other causes. Later by necessity. pregnant women was 0.8 percent. By that year, Médecins Sans Frontières 2003, it had more than doubled. Rising Since nobody else in the group trained Chit Wen and Poo Hjoo to de- HIV rates prompted the clinic to take a had medical training, Dr. Cynthia be- tect malaria in slides of patients’ blood more proactive approach to the increas- gan holding informal two hour “dis- using a microscope that had been doing risk of infection. To augment its cussions” at night to teach some of the nated to the clinic. previous program of general HIV edu- students practical medical skills. Over Around this time, battles raged at cation in factories, clinic staff set up a the years, the trainings became more Wang Ka, a Karen stronghold near Mae voluntary counseling and testing pro- extensive, evolving from a week-long Sot, and this unrest precipitated an in- gram to target people at risk for HIV. seminar, to maternal/child health train- crease in clinic staff. Many of the ado- People who identifi ed themselves as ing, and fi nally into comprehensive lescent students from the Karen areas HIV positive were invited to join a primary health care training. were sent to the clinic for safety. When support network and become peer edu- Today, in partnership with the Wang Ka ultimately fell to junta forces, cators or home-based health workers Burma Medical Association (BMA) many of the young students made the for other HIV patients. Today, in an ef- and volunteer professionals, the clinic clinic their new home, trained as med- fort to decrease HIV transmission from offers a six-month community health ics and became an integral part of the mother to child, the clinic collaborates worker course that can be upgraded staff. with Mae Sot Hospital to provide anti- with an additional ten months of medic In the refugee and IDP camps, the retroviral treatment to pregnant HIV- training. The clinic also offers special- older students began to marry and start positive women and newborns. Cur- ized training in obstetric emergencies, families. When mothers-to-be were rently, 13 HIV-positive patients are pediatrics, eye and dental health, coun- ready to deliver their babies, they came treated with anti-retroviral drugs and selling, laboratory work, prosthetics to the clinic and slept in the adjacent the clinic continues to work with Mae and minor surgery, fi eld medicine for room to Dr. Cynthia and Naw Htoo. Sot Hospital to increase the number of backpack health workers and repro- For the babies who came at night, Dr. patients eligible for treatment. ductive health for traditional birth at- Cynthia and Naw Htoo were right there While the clinic was focused pri- tendants. Backpack health workers to help the mothers through their labor marily on the medical needs of those provide basic mobile medical care to and delivery. on the Thai side of the border, as well village communities inside Burma, and In 1995, in response to growing as those who could make the cross- traditional birth attendants (similar to need, the clinic set up a maternal child border journey to receive health care, it midwives) integrate western medicine health program with a Saturday morn- simultaneously continued to expand its with traditional medicine to assist in ing vaccination clinic, antenatal care, outreach in Karen State. Typically, childbirth. family planning, reproductive health mobile medic teams traveled to remote IN 1990, DR. CYNTHIA WAS in services and a separate delivery room. locations on foot, carrying supplies in Papun in Karen State with a mobile The following year, 156 babies were back packs or woven bags braced by medical team when she heard a radio born at the clinic. By the year 2008, their foreheads. During the few days report about Burma’s election results: the number of women giving birth at that these teams stayed in each loca- Aung San Suu Kyi’s party, the National the clinic had risen to 2,500 per year. tion, their mobile clinics were crowded League of Democracy, had won 92 Pregnant women who were se- with patients from distant villages that percent of the vote with 98 percent verely anemic from malaria had to be in normal circumstances had no access turnout! But she simultaneously heard referred to Mae Sot Hospital for blood to health care. The need was so great gunfi re in the jungle as Karen troops transfusions. As a way of providing in- that Dr. Cynthia worked with village and the junta continued to battle. She house blood transfusions for these leaders to set up satellite fi eld clinics in realized freedom would not come over- women, the clinic decided to set up its Dooplaya and Chogali villages in 1992 night to Burma. own blood lab, complete with HIV and later in the villages of Sa Khan In 1991, the clinic expanded its testing. The lab was also equipped to Thit, Pa Hite, Mawkee and Mae La Po services, and began to open regularly screen pregnant women for HIV, hepa- Hta. from 9 to 12 in the morning to treat an titis B and syphilis. Aside from the The fi eld clinics took a holistic, increasing number of patients with ma- refugee camp hospitals, this was the community-based approach, providing laria, respiratory diseases and diarrhea fi rst time that the migrant and displaced basic medical care plus latrines, nurs- as well as gunshot wounds and land- populations effectively had access to ery schools, nutrition, immunizations, 6 | FROM RICE COOKER TO AUTOCLAVE vitamins, deworming, simple clean- side Burma. Four remain in prison. school accommodates 440 boarders, water systems and training in safe de- Over the years, local health pro- and coordinates a health, vision and livery techniques for traditional birth viders have proven themselves to be dental program for 58 local migrant attendants. Unfortunately, within fi ve the safest, most effective and sustain- schools. Last year, the clinic also pro- years the military had attacked and de- able way to provide health care in re- vided emergency funds for food and stroyed every fi eld clinic except one. mote rural areas affected by armed shelter for 1,440 unaccompanied dis- Today, only Pa Hite survives; it is a re- confl ict. The Back Pack model utilizes placed children in migrant areas of mote jungle clinic which from Mae Sot local capacity and knowledge by train- Thailand and 295 children displaced in involves a journey of six hours by road, ing local people and sending them back war zones inside Burma. another six hours by boat and fi nally a to work in their own communities. An unprecedented number of six or more hour walk. Typically, Back Pack teams journey to Burmese migrant and refugee families In 1998, the year after the clinics headquarters in Mae Sot every six have poured over the border into Thai- in Chogali and Sukhundit were de- months for more supplies and training. land since the increased military offen- stroyed, Mae Tao Clinic worked with When Chogali and Sukhundit fell sives of 2007 began in the eastern eth- medical partners from Karen, Karenni in 1997, the fi eld clinics’ medics fl ed to nic areas of Burma. They have come and Mon States to organize the Back Mae Sot with the nursery school teach- seeking safety, jobs and medical care Pack Health Worker Team (BPHWT). er and a dozen young students. Dr. as the Myanmar military steps up at- The group’s mission is to provide pri- Cynthia built an open-air bamboo tacks in confl ict zones, destroys vil- mary health care in rural and ethnic school for the children in the fi elds be- lages, rice fi elds and food stores, ter- armed confl ict areas where medical hind the clinic; later they moved to rorizes women, and deprives people of care is scarce or non-existent. Initially Hway Kaloke refugee camp where basic human rights, including the right there were 32 backpack teams with 120 they were able to attend an established to livelihood. health workers. Currently, 80 teams, school and live in a treehouse dormi- The Saffron Revolution in Sep- with three to fi ve members each, de- tory known as the Bamboo Children’s tember 2007 as well as Cyclone Nargis liver health services and education to Home. After Hway Kaloke was torched in May 2008 also forced more children more than 160,000 displaced people in multiple times, the children moved to to seek safety and education across the territory including Arakan, Pa O, Shan Umpium Mai Refugee camp where border. After the September uprising and Lahu areas. Back pack health they now attend school and are cared in which more than 100,000 monks work is crucial, but dangerous. The for by clinic staff. Today, the Bamboo and unarmed citizens demonstrated risks include capture, imprisonment, Children’s Home in Umpium Mai against the military dictatorship, the injury from landmines, rape and death. houses 154 unaccompanied children. government closed many monastery In the past decade, seven Back Pack Apart from the Bamboo Chil- schools, a traditional source of educa- health workers and a traditional birth dren’s Home, the clinic also runs a day tion for the children of families who attendant have been killed and six ar- school for 1,200 students (children of cannot afford the moribund state edu- rested while delivering health care in- migrant workers and clinic staff). The cation system in Burma. Although the

Original clinic building

FROM RICE COOKER TO AUTOCLAVE | 7 tend Thai schools providing that fees are paid. CCPCR is set to publish a report documenting the violence, poverty and exploitation faced by migrant children. The goal of the report is to raise awareness among the children themselves as to what their rights are, and to learn how to speak out and seek help. It will also be used as an advocacy tool to education system is technically free, lobby for legal protection for these vul- attention in a system where doctors re- the bribes and the fi nancial burden of nerable children. ceive low salaries and are infrequently providing textbooks and contributing The Mae Tao Clinic, in partner- paid, as is common in the Burmese to teachers’ salaries, for example, make ship with community groups and aca- civil service. Meanwhile, access to even basic education untenable for demic researchers, is also conducting healthcare in the rural areas affected by many impoverished families in Bur- research this year on the health of mi- confl ict is close to non-existent. ma. grant school children and quality of Nearly half of the patients at Mae All of these factors - war, poverty, care for Burmese migrant women who Tao Clinic are “medical migrants” who displaced families, torn communities, have had miscarriages or self-abor- cross the border seeking health care lack of rights – force children into vul- tions. that is normally unavailable to them in nerable situations. Children face ex- Why research? In Burma, the their own country. “When I look at the ploitation in factories, farms, brothels State Peace and Development Council clinic, I see people working very hard,” and dysfunctional families on both (SPDC) tightly controls information Dr. Cynthia says. “Sometimes, there’s sides of the border. In response, the and much of what it relates to the pub- a lot of pressure both psychologically Mae Tao Clinic and several communi- lic through state-controlled media and and fi nancially. [Staff have] been away ty-based organizations set up the Com- government ministries is propaganda. from their family for many years, and mittee for the Protection and Promo- “Research provides accurate informa- they always hope to go back home. tion of Child Rights (CPPCR), as well tion,” Dr. Cynthia says, so the commu- The people we serve have the same as a safe house for abused and aban- nity can advocate for causes based on feelings. I think everybody has sad doned children. CCPCR has held real numbers and choose how to re- feelings: When can we go back to our workshops which teach vulnerable spond to health care needs in an ethical homeland? But the problems in Burma communities how to avoid predatory and appropriate way. Research can cannot be solved quickly. Even if the employers, and is working on a Child identify barriers to health care, gaps in SPDC collapses, or the political oppo- Protection Policy and minimum stan- service provision and can show which sition wins the election, the country is dard of care for children in boarding services should be improved. still traumatized by landmines, prosti- houses. Looking ahead, the Clinic plans tution, street children, broken families. In 2008, the clinic worked with to work with community groups and People have lost their dignity and iden- Thai authorities to develop a delivery Thai supporters to develop the Suwan tity. Health services and education are certifi cate to issue to all babies born at Nimit Foundation (which translates as not accessible to the people. All this the clinic, enabling their parents to lat- “Golden Dreams”). This new Thai- cannot be fi xed within a few years. So er obtain a Thai birth certifi cate for registered NGO will work on issues we will expand as long as we need to their child. The certifi cate does not related to migrant schools, community provide health services for people from give Thai nationality or citizenship, but education, health outreach and child Burma. Wherever there are poor in the does give the stateless children a rec- protection. The MTC also hopes to es- community, we will continue to ognized birthplace and the right to at- tablish a community training center for serve.” Burmese organizations in the Mae Sot area. Across the border in Burma, the health care and economic system continue to deteriorate, forcing more and more people to leave their homeland to survive. It has commonly been reported that patients in Burmese hospitals have had to pay special fees merely to receive an adequate level of medical

8 | FROM RICE COOKER TO AUTOCLAVE THAILAND - BURMA BORDER SITUATION

The fi rst wave of Burmese refugees arrived in Thailand in 1984 when a major Burmese Army offensive broke through front the front lines of the Kar- en National Liberation Army (KNLA) forces, opposite the Tak Province of Thailand. This fi rst group of 10,000 refugees remained in Thailand after the Burmese Army was able to maintain the territory it had gained.2 The Karen National Union (KNU) and its armed wing the KNLA, has been in rebellion since the late-1940’s, with aspirations of independence from the Burmese state. The Burmese Army sought to strengthen its position in Karen State from 1984 to 1994, and followed this with the sacking of Manerplaw, the KNU headquarters in 1995. After the fall of Manerplaw, the SPDC army forces began a campaign of assimilat- ing the ethnic areas through forced relocations. With each escalation of confl ict, refugees and migrant workers have streamed across the border to Thailand either as a result of confl ict, forced relocation, or general economic hardship. Nearly 3,000 ethnic villages have been destroyed since 1996 affect- ing over one million people. It is likely democratic state, the ethnic groups as- refuge in ethnic controlled areas. The that more than 300,000 have fl ed to pired to independence from the Bur- ‘student’ camp numbers declined Thailand as refugees (the majority of mese state. An uneasy partnership be- quickly from 10,000 in 1988 to 3,000 those being Shan and not recognized gan with the students establishing in 1989. By 1997, the Burmese Army by the Thai government). In 2008 offi ces at the Karen National Union took control of the border area which there were estimated to be over 500,000 (KNU) headquarters at Manerplaw, pushed the remaining ‘student’ camps internally displaced persons (IDPs) in and also setting up about 30 of their into Thailand. At this time, most of the eastern states and divisions of Bur- own ‘student’ camps. their numbers were integrated into ref- ma bordering Thailand.3 Throughout this book, camps are ugee camps. The term ‘student’ is In a parallel development to the mentioned in three contexts; used, although the groups consisted of subjugation of the rural ethnic minority Refugee camps in Thailand com- students, teachers, university profes- areas, the democracy movement crys- prised (at least initially), of border eth- sors, young professionals, monks, and tallized in 1988 when students and nic minorities fl eeing confl ict, the fi rst other activists. monks participated in mass demonstra- of which was established in 1984. At IDP camps comprised of those tions against the military. When the the end of 2008 the population in refu- forced to relocate internally in Burma uprising was violently suppressed on gee camps in Thailand was estimated since 1996. This population includes September 18th, about 10,000 ‘student’ at around 150,000, including many un- approximately 224,000 people current- activists fl ed to the Thailand-Burma registered people.4 ly in temporary settlements of ceasefi re border. While the students aspired to a ‘Student’ camps comprised of the areas administered by ethnic nationali- pro-democracy activist groups who ties authorities.5 2 For further detail on the border confl ict, refer to TBBC 2008 Report, Appendix F. had fl ed mainly from Rangoon to take Mae Tao Clinic’s current patient 3 TBBC 2008 Report, page 159. 4 TBBC 2008 Report, page 159. 5 TBBC 2008 Report, page 162. FROM RICE COOKER TO AUTOCLAVE | 9 at times reside in boarding houses or other informal living arrangements which are often overcrowded. There are usually very few adults present which results in the older children caring for younger children. This makes early identifi cation of health problems diffi cult. Even after identifi cation, there is typically little funding available for transport or treatment expenses. Refugee camps in Thailand administered and managed by INGOs and CBOs have clinics and/or hospitals onsite. At times however, their patients are referred to MTC either due to a special patient need or preference. Ad- ditionally, cross border patients seek health care at MTC for a variety of reasons. They may not have access to health care in Burma due to their security situation or political status. If they do have access and can afford associated costs, patients report that care is expensive and of poor quality. Many patients are forced to make the journey to the MTC because of a lack of service provision or prohibitive costs in Burma. This can sometimes entail a journey of thousands of kilometers. These cross-border patients come from both civil and IDP populations. Al- though diffi cult to confi rm or qualify, population, listed below, comes from Even though the migrant popula- research suggests that: “Burma’s an overlapping constellation of groups, tion is diffi cult to quantify, it represents healthcare system is the most discrimi- each facing different challenges in an enormous group with unmet health natory in the ASEAN region, with re- health care prevention, education and care needs. The Burmese migrant pop- sponsiveness likely to depend upon an treatment: ulation is typically estimated at about 2 individual’s ethnic group, income lev- • Migrant workers and their million, most of whom have little ac- el, or civilian versus military status. families living in Thailand, population cess to health care, are exposed to trop- The health problems are exacerbated estimated at 2 million. ical and infectious diseases, and have by the ongoing armed confl ict, which • Unaccompanied or orphaned little access to pre-natal care and over- disproportionately affects the ethnic children living in Thailand all preventative care. Moreover, many groups.”7 • Refugees in camps in Thai- migrant workers do not possess legal Naturally, any other patient who land (est. 150,000) residency in Thailand; therefore they ‘falls through the cracks’ may seek care • Cross-border patients from have diffi culty travelling to a health at Mae Tao Clinic. For example, mem- civil society unable to obtain or afford care provider without fear of arrest, ha- bers of the non-state armed groups, health care in Burma rassment, or deportation, and don’t military, government in exile, monks, • Internally displaced persons have legal access to Thai health pro- and others from all states of Burma (IDPs) living in camps or in temporary viders. On the positive side, CBOs can also seek care at MTC. locations in Burma (estimated to be be- often access these populations in their tween 500,000 and 2 million)6 places of employment, such as in fac- 7 “Burma: The Impact of Armed Confl ict on 6 “Burma: The Impact of Armed Confl ict on tories, for health and reproductive edu- the Children of Burma”, submission by the Bur- the Children of Burma”, submission by the Bur- cation initiatives. ma UN Service Offi ce – New York & the Human ma UN Service Offi ce – New York & the Human Rights Documentation Unit, August 2002., p. Rights Documentation Unit, August 2002. Children of migrant populations 10. 10 | FROM RICE COOKER TO AUTOCLAVE CLINIC STAFF

Clinic Staff as of 2009 Male Female Total Clinical Service 125 153 278 Outreach / Social 70 42 112 Pa Hite Clinic (IDP) 42 62 104 Child Protection Service 54 71 125 International / Thai Volunteer 4 11 15 Total 295 339 634

Today the clinic’s staff spans a shade trees at the clinic and listen to range of age, experience, and ethnicity. their story, they will proudly explain A visitor to the clinic might hear three that they came to Mae Tao Clinic to re- or four languages being used at any ceive training, to hope for change in given moment as the staff go about Burma, and that they hope to return their work. Medics volley in conversa- someday to help their people. They ex- tion, jumping between Burmese, Eng- plain that there are few such opportuni- lish and their own ethnic languages. ties for them to gain the training and Of course, the original founders of the experience necessary to assist their clinic were from the Karen and Bur- people in Arakan State equal to the man ethnic groups, however, this was ones that they receive at the clinic. due mainly to the proximity of the clin- While in the clinic, the medics ic to Karen State, and the linguistic wear uniforms and identiﬁ cation badg- needs of the majority of patients. De- es and are respected authorities, how- spite the traditionally large contingent ever, they dare not travel far from the of Karen speaking staff, recent years clinic, since most do not have legal sta- have shown a growing diversity in the tus in Thailand. Whilst this is restric- languages used in the daily running of tive, the limitations have led to a lively the clinic’s operations. An example of social scene in and around the clinic. this diversity is the clinic’s small com- Births, weddings, deaths, and festivals munity of Arkanese speaking medics are celebrated within the clinic society, from Arakan State in western Burma. with staff quarters centered around the In their case, the journey to the clinic clinic grounds. When Dr. Cynthia re- was long and treacherous, crossing the marks, “This is not only a clinic, it is entire breadth of the country. If a visi- also a village”, one can see that this ap- tor takes the time to sit under one of the plies to both patients and staff.

FROM RICE COOKER TO AUTOCLAVE | 11 A COMMUNITY OF ORGANIZATIONS

Mae Tao Clinic has evolved from a service provider into a network of organizations. Some organizations are part of the clinic umbrella, such as the Children’s Development Center, while others which remain technically separate are tightly woven into the fabric of the clinic, such as Karen Women’s Organization. When a meeting is held at the clinic, one can observe how a tight community, a little chaos, a lot of mobile phone calls and text messages, a few bicycles and motorbikes and a few rides hitched from a friend all make the process work. Sometimes there is too much chaos and not enough coordination and communication; other times, things seem to magically come together. As Mahn Mahn from Backpack Health Worker Team exclaims, “There is never enough communication and coordination!” With the clinic’s work a constant struggle between tight resources, high demand and a multicultural staff of varying experience, this is hardly surprising. Throughout the book, many of the organizations within the clinic’s network are highlighted. The reader will begin to realize that the community-based organization and collaboration has been increasing exponentially during the last ten years. The clinic’s shift from service provider to advocacy, prevention, and child protection has been one element that has precipitated this change. The other element has been the expanding border and migrant populations; community based organizations are their only source of health care and education. One element that is frequently overlooked in the success of these collaborations is the spirit of the Burmese, Karen, and multiple other ethnic groups; a spirit that allows these diverse groups to help themselves and each other and has led to a ﬂ ourishing of community-based activities. Any reader of this book will also be interested to learn about the following MTC CBO partners, who are recognized here for their efforts throughout the years:

• Adolescent Reproductive Health Network (ARHN) • Assistance Association for Political Prisoners (Burma) • All Burma Student Democratic Front (ABSDF) • Back Pack Health Worker Team (BPHWT) • Burma Labour Solidarity Organisation • Burma Medical Association (BMA) • Burmese Lawyers’ Council (BLC) • Burmese Migrant Workers Education Committee (BMWEC) • Burmese Women’s Union (BWU) • Care Villa • Committee for the Protection and Promotion of Child Rights (CPPCR) • Coordination Team for the Displaced and Promotion of Child Rights (CTDCE) • Human Rights Education Institute of Burma (HREIB) • Kachin Women’s Association Thailand (KWAT) • Karen Department of Health and Welfare (KDHW) • Karen Education Department (KED) • Karen Refugee Committee • Karen Student Network Group (KSNG) • Karen Teacher Working Group • Karen Women’s Organisation (KWO) • Karen Youth Organisation (KYO) • Karenni Health Worker Association (KHWA) • Lahu Women’s Organisation (LWO) • Migrant Assistance Program (MAP) • National Health and Education Committee (NHEC) • Palaung Women’s Organisation (PWO) • Shan Health Committee (SHC) • Shan Women’s Action Network • Social Action for Women (SAW) • Student Youth Congress of Burma (SYCB) • Women’s League of Burma (WLB) • Yaung Chi Oo Workers Association

12 | FROM RICE COOKER TO AUTOCLAVE 1989 – 1994: THE BEGINNING

MTC in 1989 - 1990

FROM RICE COOKER TO AUTOCLAVE | 13 Patients referral to Mae Sot Hospital. REFERRAL PROGRAM MANY PEOPLE DON’T REL- severe fractures in children, and myo- tion, and all blood donor samples are IZE that the Referral Program is the ma, uterine prolapse and ovarian cysts sent for screening, and some biopsy for longest running program at Mae Tao in adult cases. testing. MTC also supplies 40 baht per Clinic. Before the staff of the clinic patient per day for food while at the Less than 1% of cases are referred to hospi- had the supplies and capacity to treat tal, but require 15% of the clinic’s budget. Mae Sot Hospital. The referral team many of the patients that they saw, they provides all transportation, as it offers were referring them to Mae Sot Hospi- The referral team consists of 10 security which helps patients avoid be- tal (MSH). In 1988, student camps staff, managed by Saw Tin Shwe. The ing arrested. were established along the border, role of the staff is to be in regular contact with the clinic departments, coor- The referral staff speaks several lan- mainly by students who had come from guages ... Burmese, Pwo Karen, central Burma, and were not from Kar- dinating the travel of referral patients Sgaw Karen, Thai, English, and oth- en State or border areas. In the begin- to Mae Sot Hospital and then acting as ers. translator and social support for pa- ning, the cases that couldn’t be treated Of course not all cases that go be- tients during their visit to the hospital. in the student camps were referred to yond the services of the clinic will ac- For this reason, it is necessary that MSH through coordination at MTC. tually enter the Referral Program. Mae these staff members speak several lan- At this time, MTC was more like a pa- Tao Clinic allocates a monthly budget guages each, possibly including Bur- tient house, sending 20-25 cases per which is used to pay for treatment at mese, Po Karen, Ska Karen, Thai, and month to Mae Sot Hospital. Today the larger service providers such as Mae English, and to possess a Thai identifi - clinic is able to treat malaria cases, and Sot Hospital. Emergency and the most cation card allowing them to travel deal with more severe injuries, but severe cases get referred fi rst, but non- freely in Mae Sot without threat of ar- there are still patients that require ser- emergency cases do not often get re- rest. Each morning the referral patients vices beyond the clinic’s capacity. ferred. Most referred cases are surgi- are gathered at 8:00 am for transfer (an The majority of the patients that cal cases, as medical cases can be often tricky task in the torrential down- enter the Referral Program have treated at the clinic, with exceptions pours of rainy season, as the Referral crossed the border from Burma for being chronic diabetes cases, and HIV Program does not actually have a spec- medical services. They are seeking positive pregnant women. ifi ed offi ce or covered area for patients services that are either not available in MTC does not handle all patient to meet). Each patient is assigned to a Burma, or that they cannot afford; the referrals alone. Since 2004, the Inter- member of the referral staff. Along journey to Mae Tao Clinic however, national Committee of the Red Cross with the patients, blood samples are means free health care services. Some (ICRC) has been supporting all land- taken to the hospital for testing of renal of the most common cases seen for re- mine and gunshot wound cases for the function, liver function, thyroid func- ferral are congenital heart disease and fi rst visit to MSH. For follow-up vis- 14 | FROM RICE COOKER TO AUTOCLAVE its, which most of these complicated tients or patients’ parents need to return this poses a greater challenge than one cases require, the clinic covers the cost. home to care for other children or re- might think. Saw Tin Shwe explains Since 2003, the Burma Children Medi- turn to work to support the rest of the that not many medically trained staff cal Fund has supported complex cases family. When asked what he wishes are interested in working with the re- for children under twenty, where the for the Referral Program Saw Tin Shwe ferral team, as they do not actually patient is considered likely to respond easily responds, “more money.” With practice medicine, but rather facilitate well to treatment. As discussed further a larger budget there would never be a the opportunity for patients to receive in “2000 – 2004: Building Capacity”, question of which patient takes prece- medical care elsewhere. Moreover, The Burma Adult Medical Fund simi- dence, or who is more severely ill. At even if a medic were interested, the larly supports complex adult cases, this point, non-emergency cases do not likelihood that they also speak Bur- where the patient is considered likely get referred, but with a larger budget mese, Karen, and Thai, and possess a to respond well to treatment. In all of patients suffering from a wider array of Thai identifi cation card is unlikely. In- these instances the majority are surgi- conditions could also receive treat- dividuals who have strong language cal cases, with exceptions being heart ment. skills and possess a Thai identifi cation conditions that will respond to medica- Emergency obstetrical care com- card are understood to be very valuable tion instead of surgery. prised of 12% referral cases in late assets to any organization, making 2008, 22% emergency medical cases, them highly employable. Many of Tuberculosis remains a major concern for the referral team. There are few treatment and 25% general surgical cases in late these skilled individuals are already options for cross-border patients. 2008. Two imposing challenges are employed by INGOs, and receive a sal- chronic budget limitations at Mae Tao ary much larger than most CBOs can For many years, MTC referred Clinic to refer more patients, and ca- offer, thereby depriving CBOs of a TB patients to a Médecins Sans Fron- pacity at Mae Sot Hospital to handle much needed resource. tières (MSF) program in Mae Sot for the ever increasing caseload. Still, Saw Tin Shwe has hope; he comprehensive treatment. However, MTC sees many neonatal compli- hopes that more staff will understand with MSF discontinuing this program, cations. Along the border, most deliv- the benefi ts of working with the Refer- MTC isn’t able to refer most TB pa- eries still occur at home. As a result, ral Program. Because the Referral Pro- tients for treatment. Beginning in patients come to MTC after serious gram coordinates closely with so many 2008, World Vision has established a problems arise such as premature la- of the clinic departments, it provides less comprehensive TB treatment pro- bor, infection or hemorrhage. When employees a unique opportunity to gram in Mae Sot that does not include these cases have to be referred, the learn about and understand the func- cross border patients. costs involved are quite high, so the tioning of the clinic on a much larger The most common referral cases are from clinic continues to upgrade it’s neona- scale than if working as a medic in only Reproductive Health Inpatient Depart- tal and delivery skill set. one department. Also, to be part of the ment, and include cesarean deliveries, Besides an unlimited budget, Saw referral team means providing invalu- post-delivery complications, uterine my- oma, uterine prolapse, and uterine cysts. Tin Shwe expresses a few other wishes able support to the patients: providing for the program: as the only referral security in transportation, providing The manager of the Referral Pro- team member with a medical back- comforting support to sick patients gram, Saw Tin Shwe, is saddened and ground, it is nearly impossible for Saw who are in a very unfamiliar environ- frustrated about the patients who still Tin Shwe to take a day off. He hopes ment, and acting as a translator and to go untreated. He suggests that even if that in the near future the Referral Pro- ensure illnesses aren’t mistreated or go patients are presented with the oppor- gram gains 2 or 3 new staff members untreated all together. tunity of entering one of these referral with a medical background, although programs and go to Chiang Mai Hospi- tal for treatment, they do not always take the offer. From his experiences at the clinic, Saw Tin Shwe provides a variety of reasons as to why this happens: a patient or patient’s parents may lack general health knowledge and fail to understand the severity of the illness, the patients and their family fear traveling to Chiang Mai where they do not speak the language, and do not possess offi cial documentation beyond the referral notice from MSH, or the pa- Patients waiting to go to Mae Sot Hospital.

FROM RICE COOKER TO AUTOCLAVE | 15 First surgery in MTC, Dr. Cynthia Maung in surgery, student observing, 1989

DRESSING, SURGERY, AND TRAUMA

It is common for many to assume ical patients and one for dressing (trau- to upgrade the surgical facility. that the trauma department was the fi rst ma) patients. The current Surgery De- These trainings facilitated chang- program in Mae Tao Clinic, however, partment continues to treat trauma es from 2002 when the number of sur- this is not the case. While the original cases, but has transformed into a surgeries began to increase. In 2001 the intention behind establishing the clinic gery and recovery department with an dressing services moved to a separate was to provide referral and recovery increased focus on medical cases. The building with more space for tending services, there was still a need for Dr. medics note that the changing func- to traumas. Surgical procedures were Cynthia and her team to take care of tions of the department are not just a introduced in 2002, under the instruc- burns, abscesses, and minor work inju- matter of a bigger caseload, but also a tion and supervision of international ries. Today, one might be more likely question of seeing a broader and more volunteer doctors. Department Man- to encounter complex operations such complex range of ailments. ager Saw Law Kwa recalls how he fi rst as hernia surgery, bladder stone remov- Initially trauma had one separate observed and assisted the visiting doc- al or a vasectomy. What is now known room, mostly for dressing and stitch- tor, but after about 15 patients the roles as the Dressing and Surgical Depart- ing. Starting in 1999, Norwegian changed and he was performing his ment was originally known simply as trained medics (Trauma Care Founda- fi rst hernia operation. “Dressings”, and later, “Trauma”, and tion) trained local medics over the The fi rst surgical space was small was part of the single department of the course of three years; these local med- and dark, with the staff quarters later original clinic facility. The staff tended ics were working in the jungle, doing added on the fl oor above it. The med- to skin infections such as cellulitis, as war casualty management. This inten- ics living above were always careful to well as abscesses, some burns, and mi- sive training made more services avail- walk quietly so as not to disturb opera- nor work injuries like lacerations and able and upgraded surgical procedures. tions going on below. A new operating nail punctures. Originally there was Naturally, the team of health workers theatre was built in 2004, offering a one room with two beds – one for med- who received training was very eager much larger and brighter air-condi-

16 | FROM RICE COOKER TO AUTOCLAVE Annual Trauma Caseload tions to every rule though. Law Kwa recalls the story of Khun Myo Myat, a previous patient who is now a staff member in the department. At the end of 2006, Khun Myo Myat had an acci- dent while working at a construction site in Bangkok. He fell from a tower, severely fracturing a leg and his jaw- bone. Not long after this, he was arrested by police, and sent back to the border crossing in Mae Sot. Khun Myo Myat was still suffering from his injuries and did not know what to do; he certainly didn’t want to cross the border back into Burma. Luckily, a kind tioned space with improved equipment, tients receive daily dressing changes, stranger at the border brought Khun allowing staff to more comfortably and rehabilitation support for as long Myo Myat to the clinic. When he fi rst perform a variety of surgeries, includ- as necessary, which could be anywhere arrived at the clinic he could not speak ing hernia operations, hydrocele, va- from one to six months, or even longer to anyone, and was thus unable to ex- sectomy, skin grafts after burns or cel- if there are post-operative complica- plain his story. Regardless, the staff lulitis, amputation, bladder stone tions. Patients with severe fractures tended to his wounds and waited for removal, and penile repair after infec- usually require the longest rehabilita- his jaw to heal. Once the wounds had tion resulting from penile enhancement tion time. healed, about four months later, Khun (coconut oil is injected into the penis to Law Kwa explains that they often Myo Myat was faced with the decision increase size and rigidity). have patients who want to continue of what to do and where to go. He had Burns are a very common type of staying at the clinic after their treat- left Burma nearly 20 years earlier, his trauma treated at the clinic. Some of ment is fi nished. This is understand- parents were dead, and he didn’t know the most preventable traumas are the able, as the clinic provides a safe envi- where his sister was; he didn’t know accidental burns of children. Called ronment, with free shelter and food; a where to go. The department staff fi re-pit burns, children come in with much easier existence than what many spoke with Dr. Cynthia, and it was de- major burns to the feet and legs, as a will have to face after leaving the clin- cided that Khun Myo Myat could stay result of running through the ash of ic. Unfortunately the clinic cannot al- on as a cleaner in the surgical depart- fi res thought to have gone out. Fires low these patients to stay; they must ment. When asked why Khun Myo are often built under stilt houses as a make space for the many patients com- Myat was an exception to the rule, Law way to ward off mosquitoes during the ing in behind them. There are excep- Kwa responds, “He is from Shan night, so if children are up in the morning before their parents, or the parents are already working and cannot tend to the children, the results can be devastating. The clinic is never without one of these fi re-pit burn cases. For severe cases that cannot be treated at MTC, patients are referred to Mae Sot Hospital. The most common referral cases are severe fractures (open or closed), abdominal injury, head injury, landmine injuries, and severe burns. After being treated at the hospital, patients return to MTC for post-operative care. If the patient has the ability to walk they will stay in the Patient House at the back of the clinic property; if not, they will stay in the Trauma and Surgery Department. These pa- Dressing a burn.

FROM RICE COOKER TO AUTOCLAVE | 17 state….a long distance to travel. We can also say that he is lucky.” Lucky indeed. Law Kwa would like to reduce the need for patient referrals to MSH, saving the clinic money and patients undue stress. Currently, the clinic is fortunate to have volunteer doctors that come for short-term visits and perform very specialized services, such as tali- pes surgeries, but the department would like a more sustainable solution and to be able to further develop the skills of the staff. Adding new procedures to the list already performed by the department would, however, require a great amount of training in new skills and knowledge, and most importantly, regular ongoing support from trained professionals. Because it is diffi cult Giving local anaesthetic. for international doctors to visit for extended periods of time, and the clinic department takes a pragmatic approach, the clinic once they have returned cannot offer fi nancial support to volun- which revolves around patient educa- home, thereby acting as conduits of teers, the likelihood of this seems dis- tion. First, they try to learn as much knowledge in their communities. The tant, but the staff continues to hope. about the patient as possible in order to medics even educate patients about the The staff also expresses a wish to gain an understanding of the broader health implications of smoking, drink- work more closely with the local Thai circumstances faced by the patient. ing and risky sexual behaviors. The community, to establish more partner- They then educate the patient through counseling center is a relatively new ships and relationships, to better know confi dential conversations, supple- addition to the clinic, but already en- and understand the community that mented by educational pamphlets in joys a strong partnership with the sur- they now call ‘home’. Burmese language. Educating the pa- gical department. While the medics The surgical department shares tient yields multiple returns – the med- feel it is an integral part of their job to the challenge of psychosocial issues ics report that patients tend to talk to manage the psychosocial issues, they with the Inpatient Departments. The other patients about their experience at also appreciate the need for more extensive support for the patient and work A minor surgery in surgical department. to ensure appropriate referrals. The medics themselves suffer from psychosocial problems as well. When patients tell medics about their experiences whilst seeking health care in Burma, they feel disappointed and sometimes hopeless for the future of their homeland. The patients’ stories relating the cause of their visit to the clinic lead to mental and emotional challenges for the medics who deal with victims of trauma on a daily basis. There are also many positives associated with this type of work as well however; when asked what was the most satisfying part of their job, the medics said it was the satisfaction de- rived from treating a patient successfully and helping them get back to their families and jobs.

18 | FROM RICE COOKER TO AUTOCLAVE First baby born in MTC, named Zar Ni Chit.

REPRODUCTIVE HEALTH

The Reproductive Health Pro- laria, HIV, sexually transmitted infec- of life and death; doing so with a tradi- gram’s goals are to keep mothers strong tions and anemia. tional sliver of bamboo risks neonatal and give all children a healthy start. The clinic provides in-depth tetanus, a terrible disease that can be These themes have been central to training in obstetrics and obstetric prevented by using a sterilized razor MTC’s mission since 1990, when Dr. emergencies to medics and midwives; blade instead. Cynthia delivered a student’s baby on it has also trained hundreds of back The need for reproductive health the fl oor of the dilapidated house where pack health workers and traditional services at the clinic was identifi ed in she lived and cared for patients recov- birth attendants in safe birth techniques late 1989, when expectant mothers be- ering from malaria. Mothers and chil- and provided them with life-saving gan coming to the clinic to deliver their dren are the future, she told graduating birth kits and supplies for use in remote babies at all hours of the day and night, students at the fi rst primary health-care villages and ethnic confl ict areas. In and to receive care from Dr. Cynthia training in 1996. “For a good future, the jungle, something as simple as cut- and Naw Htoo, who now leads the Re- do something good for mothers and ting an umbilical cord can be a matter productive Health Outpatient Depart- children.” Young medics took the message to heart, emblazoning the slogan Delivery at MTC by years on their shirts. Today, the Reproductive Health Department is located in a breezy light- fi lled concrete building with a shaded porch where mothers often cuddle swaddled newborns while staff members sit in a circle, assembling safe birth kits and rolling cotton hanks into swabs. The Reproductive Health De- partment’s inpatient and outpatient sections provide comprehensive women’s services including family planning, gynecology, normal and complicated labor and delivery, neonatal care, and post-abortion care. Its antenatal care program offers screening for ma- FROM RICE COOKER TO AUTOCLAVE | 19 ment. Naw Htoo, who started out with born at the clinic. As the number of die in childbirth; other mothers leave no medical training, recalls feeling fas- deliveries increased, the clinic added a their infants because poverty or other cinated, sympathetic and scared the second delivery room. Naw Sophia, circumstances prevent them from profi rst time she watched Dr. Cynthia de- who now leads the Reproductive viding a good home. In the case of liver a baby. Since she was the only Health Inpatient department, recalls abandoned children, medics care for other woman on the clinic’s small staff, that the delivery rooms in those days the infants in the in-patient department she realized she had to watch and learn; were narrow, dark and they stank; suf- for several months in case family mem- what if a woman went into labor when fering as they did from their proximity bers return to claim them. After that, Dr. Cynthia was not available? to nearby toilets. In 2001, the clinic the Clinic works with community- built a new, bright and airy building for based organizations to fi nd safe local Maternal mortality rates are over 1,000 per 100,000 live births in the Eastern reproductive health with support from homes for these children. Burma confl ict zones. This compares the Women’s Commission for Refugee The Reproductive Health Pro- to 360 in the rest of Burma and 44 per Women and Children, as part of the gram has come a long way since those 8 100,000 live births in Thailand. Averting Maternal Death and Disabili- early days when Dr. Cynthia and Naw Back then, the facilities for ex- ty Program. The clinic added programs Htoo were the only ones at the clinic for safe motherhood, sexually trans- who could deliver babies. Thanks to 8 Chronic Emergency: Health and Human mitted infections and HIV/AIDs, ado- in-depth obstetric training, medics in Rights in Eastern Burma, report by Backpack Healthworker Team. lescent health care and gender-based the reproductive health department can

Delivery certifi cate for new born babies. pecting mothers were basic and women violence prevention. now manage prolonged labor, handle in labor had to climb a ladder to get to About ten babies are abandoned in the obstetric emergencies, do vacuum ex- the delivery room, where they gave clinic each year. tractions and prevent most post-partum birth and then recovered as Dr. Cynthia hemorrhages and manage those that do A recent challenge has been fi nd- and Naw Htoo cleaned up around them. occur. ing resources to care for cancer patients In 1995, the clinic set up a maternal The Inpatient department now who come for pain treatment at the child health program with a separate has 25 beds, but Naw Sophia laments, clinic and stay until they die because ground-fl oor delivery room. It offered “It’s still not enough!” Even though they have no money and nowhere else a Saturday morning vaccination clinic, the clinic has expanded its capacity in to go. The department often runs out family planning, reproductive health this respect, the need for quality repro- of much needed pain medication; fi nd- care, gynecological services and ante- ductive health care continues to grow ing more is high on their wish list. An- natal care. Pregnant women went as more and more patients come to the other huge challenge comes in the form home from their antenatal visit carry- clinic for obstetric and gynecologic of small swaddled bundles - the 10 or ing small bundles of chicken eggs - a care. high iron food to help prevent anemia. so newborns orphaned and abandoned The following year, 156 babies were at the clinic every year. Some mothers

20 | FROM RICE COOKER TO AUTOCLAVE Nutrition program at Child OPD. FOOD & NUTRITION PROGRAM Patient Food Program: 400-500 etc) Child OPD, supplementary pro- Starting in 1989, a monthly ration patients per day are provided with 3 gram (HIV, abandoned baby, etc) with from Catholic Relief Organization was meals, at a cost of 700 baht per person a constantly increasing budget needs. an enormous help in meeting the clin- per month. Even before it was providing ics food provision needs, allowing the Staff and Families: 800 staff and health care services, the staff of Mae clinic staff to pick up large sacks of family members are provided with 700 Tao Clinic was providing food services rice and beans to distribute to depen- baht per month to patients. In the very early stages of dents. The initial program at MTC Supplementary Food for HIV the clinic, before the necessary medical supported 50 staff and patients, on a Patients: over 200 HIV positive indi- supplies were available, patients were budget of 6 baht per person per day. viduals are provided monthly food ra- referred to Mae Sot Hospital (MSH) This six baht per day only covered rice, tions at 350 baht per month. for treatment. MSH provides food for with cooking oil donated from time to Boarding House Staff and Chil- patients but not their attendants. Mae time. It wasn’t much, but there were dren: about 600 teachers, staff and Tao Clinic began by providing food for no complaints. boarding children are provided dry the patient and their attendants during When it was established, MTC food rations. their hospital stay and through their re- had 8 rai 10 of land, where staff grew Department Supplementary covery in the clinic’s patient house. vegetables and raised some chickens, Food: a monthly budget of 20,000 baht The food was prepared at the clinic, ducks and pigs. As MTC grew howev- is provided to inpatient departments and then staff would walk the three ki- er, the land was needed for buildings working 24 hours per day, who also lometers everyday to the hospital to rather than this small cottage industry provide for patients who cannot eat deliver food to patients who were in of farming. Dr. Cynthia muses, “Grow- rice (noodle soup). Mae Sot Hospital. Either they walked ing vegetables was always a problem Mae Sot Hospital Patients: ap- in the hot sun or monsoon rains, or for us. We are not very skilled in agri- proximately 80 patients per month are with some luck got a free ride - a mo- culture, and the water bill seemed to be provided with 30 baht per day/ torcycle taxi was an unaffordable luxu- more than the cost of just buying the Eye Surgery Program: 3 daily ry. vegetables.” For the ﬁ rst two years the meals are provided to the 400-500 ex- clinic had no separate kitchen. In time The average Burmese family spends tra patients that arrive four times per 70% of their income on food. In con- though, the clinic received donated year for a 2-week period. trast, in the United States, only 6% of timber to build a separate kitchen Milk Powder Program: OPD, household income is needed for food.9 which the staff and students construct- Mother to Child transmission preven- 9 UNFPA, “United Nations Population Fund Assistance to Myanmar’, 13 July 2001, UN Doc. tion, RH inpatient, (twin, abandoned, Proposed Projects and Programs: Recommenda- CP/FPA/MMR. tion by the Executive Director; Proposed Special 10 3.2 acres or 1.3 hectare FROM RICE COOKER TO AUTOCLAVE | 21 ed on their own. Eventually this separate kitchen became once again incorporated into the clinic facility, as the health service departments continued to expand around it in response the ever-growing number of patients. Hav- ing the kitchen so close to the health services was not appropriate however, with both staff and patients complaining of the smell. In 1999, a large patient kitchen and dining hall was built at the back of the clinic compound and a new staff kitchen was built next to this in 2007.

“This is not only a clinic; it is a village.” – Dr. Cynthia

Food Program Manager, Naw Htoo, comments on the daily challenges of managing the various food pro- Providing medical service in IDP area. grams, “The funds are fi xed, but the prices and the number of patients is not. It is diffi cult.” Adjusting for the MOBILE MEDICAL TEAMS growing number of staff and patients, Following the 1988 uprisings in access to services. The health workers as well as regular food price increases Burma the displaced population living would carry their medical supplies, and has always been a challenge and this along the Thailand-Burma border grew travel deep into the jungle on foot. was drastically augmented by the 2008 quickly, with people struggling to sur- global food crisis. With high prices Mobile Medical Teams operated from vive. Some individuals were able to and a fi xed budget, the fi rst items elim- 1991 – 1997. fi nd food, shelter, medical services, inated are the fresh foods – meat and and relative safety either in student Before the MMT could begin vegetables. Naw Htoo explains having camps that were set up in the stable ar- these trips though, they had to gain to sometimes buy food supplies on eas of Karen State, or on the Thai side permission from the local authorities to loan, “All the shop keepers know me, of the border. For many people unfor- travel and work throughout the areas of so I will go and get food in advance tunately, neither of these options was Karen state. This wasn’t easy. The when the money is not there. They feasible, and instead they struggled for rapidly growing population of pro-de- trust me. I keep my word. We have survival in the highly unstable and mocracy students arriving on the bor- worked with them for a long time. This dangerous regions of Karen State. The der was not yet well known, under- is okay for dry food, but not meat and term internally displaced persons stood, or trusted by the people living in vegetables…they have sympathy for (IDPs) was not yet being used to de- the area. The MMT had to fi rst gain us.” Naw Htoo has managed the Food scribe this population of people, and the trust of the local authorities, and Program since 1989, and her passion is there were no coordinated efforts to as- then together they discussed which ar- still evident, despite the pressing chal- sist them. The need was obvious, and eas needed the most help and which lenges posed by funding shortfalls. there was the desire to assist, but in the were actually safe enough to travel in. Despite these, and other obstacles period immediately after the uprisings Not only did the MMT need permis- faced over the last 20 years, the Food no one had the resources or stability to sion from the local authorities; they Program has grown from a service for offer this assistance. By 1991 though, also needed the assistance of the local 50 staff and patients to a comprehen- three years after the uprisings, MTC people. MMT health worker Sein Han sive program serving over 100,000 pa- was well enough established to begin puts it simply, “The most important tients, staff, family members, and providing health services to the people thing was to have local health workers school children each year, and remains still inside Karen State. The Mobile go with us.” Wherever the MMT trav- successful. The plans for the future are Medical Team (MMT) was established, eled, the local health workers would the same as those of the past – to make with health workers from MTC mak- join the team, forming a group 10-15 sure everyone who ‘passes through the ing 6-8 week trips inside Karen State to people at any given time. The local doors’ of Mae Tao Clinic is fed. bring health care to people who had no health workers knew the area and the

22 | FROM RICE COOKER TO AUTOCLAVE terrain, knew where it was safest to Nay Htoo says that the trips with the travel and how to avoid landmines and MMT were a practical test that made fi ghting. The local health workers also him a more active student. helped to gain the trust of the people Not only were they required to they encountered on their trips into the have sharp minds, but the members of jungle, who would then provide the the MMT were also required to be MMT health workers with food and physically strong and healthy. They shelter. Local people would also help had to be strong, as they traveled on the teams to carry their medical sup- foot over mountains and across rivers, plies. At all times during these forays, carrying all necessary equipment with the group was accompanied by soldiers them. They also had to be strong be- from the area. The MMT health work- cause, inevitably, they would get sick ers would live with, work with, and themselves. Sein Han explains that if treat the same people. people living in the village had dysen- MMT health worker Nay Htoo tery, so did members of the MMT – recalls how gaining the trust of the they ate what the villagers ate. “Every people was a challenge – it was under- time you returned from the jungle you standable that they would be suspicious MInor injury care for a landmine victim. brought back malaria,” says Sein Han, of strangers during this very unsafe and but “we didn’t worry about it. We got unsettling time. Furthermore, many of Operating in places where there used to it.” When the MMT would re- the people that the MMT assisted had were no health care facilities and no turn to MTC, they would take about a no experience or understanding of public health programming, the MMT month of rest, which was seen as an western medicine, and so the MMT realized that educating their patients opportunity to recover from their own had to introduce new ideas that contra- was just as important as tending to their illnesses before returning to the jungle dicted traditional thoughts and practic- illnesses. The education did not end for another trip. es. Nay Htoo remembers the challenge with the patient, but was extended to These MMT trips continued until of treating patients who had measles. the family and the community, as it 1997, at which point the program end- It was very diffi cult to convince pa- was these groups who would assume ed. Security was getting tighter, move- tients that they needed to clean their the responsibility to care for the pa- ment was more diffi cult, and the MMT skin with boiled water, and then allow tients once the MMT moved on. As the couldn’t grow fast enough to meet the the skin to cool off and be exposed to MMT would spend only one or two needs of the people; unfortunately the the air. This was in total contradiction days in each location, with a return MTC didn’t have the necessary re- to their traditional understanding, visit extremely unlikely, this was the sources. A re-coordinated effort was which was to protect the skin and not only option. Without this transmission made to address the needs of this dis- aggravate it, by not washing it and of knowledge, the efforts of the MMT placed population of people, and in keeping it wrapped under many blan- would have been rendered pointless. 1998 MTC helped to establish the Back kets. Family members were taught how to Pack Health Worker Team (BPHWT). tend to wounds and monitor illnesses, Mobile medical trip to northern Karen State It takes a certain understanding and the MMT explained to the local and perspective to succeed in the role authorities why they felt a patient of a mobile health worker. Besides be- might need to travel to a hospital when ing strong both mentally and physical- occasion demanded. ly, these individuals require the charac- The MMT health workers had to teristics of the teacher, the student, and be excellent teachers, but Nay Htoo re- the leader. It is a role that demands calls how the experience also made someone who truly understands the in- him a better student, “You must treat valuable effects of their efforts. In all cases. People are counting on you. comparison to health care services on You must be prepared with knowledge. the Thai side of the border, which by You must know this information. You western standards are still basic and re- must know where you’re going and source limited, Sein Han explains that, what types of things are happening “over there, there is nothing. To work over there.” Every time the MMT re- over there is meaningful for us. To turned to MTC in Mae Sot the health have rain in the ocean? No, to have workers scrambled to learn more, seek- rain in the dessert is more meaning- ing to upgrade their skills even further. ful.”

FROM RICE COOKER TO AUTOCLAVE | 23 Karenni, Shan, Chin, Arakan and P’Loung) were keen to set up clinics in their places of origin. These MTC alumni approached Dr Cynthia and asked if MTC would facilitate the establishment of these clinics. MTC agreed and worked to set up clinics inside Burma in ethnic areas, and on the Thai border area where groups of refugees were concentrated. MTC has an admirable record of collaboration with partners to coordinate and manage the health worker clinics, and this has enabled them to improve the running of those clinics. First Cho Gali civil clinic in 1992. Partners have cooperated with MTC on the maintenance of the clinics, such as CIVIL CLINICS the upgrading of equipment and facilities, and in the monitoring and evalua- Cho Gali, the fi rst of the civil State, and helped to facilitate the estab- tion of the civil clinics. Below, three clinics, provided the framework for the lishment of clinics in other ethnic areas medics recall their experiences work- subsequent clinics. It was constructed as well. When the clinics were estab- ing with civil clinics established by by the local villagers using bamboo lished, they treated common illnesses MTC. and leaves. It provided services to such as malaria and diarrhea. A promi- people from approximately eight sur- nent feature of these clinics was their rounding villages with both outpatient cooperation with local midwives, or CHO GALI CLINIC: and inpatient services, and ran three traditional birth attendants (TBAs), main programs that were integrated who were the frontline health service Cho Gali was the fi rst clinic es- with the medical services: maternal providers of maternal health care in tablished by MTC. Initially, villagers health care, school health, and water isolated areas. The clinics worked with were skeptical of the clinic and contin- and sanitation. TBAs to enhance safe practices for ued to use traditional medicines. Even- MTC did not have the resources birth - including identifying the signs tually, as the services proved effective, to provide a salary for the medics. of danger during pregnancy and labour villagers came to trust the clinic and to Each staff member received food and - and on introducing safe hygiene prac- use it. According to Say Hae, a teacher board, and 2 longyis and 2 shirts a year. tices. who worked in the area for many years Each month the clinic as a whole re- Education was another defi ning before and after the clinic was set up; ceived 1 bar of soap, 1 tube of tooth- feature of the civil clinics, which were the clinic had a positive effect, particu- paste, and a ½ kilo of washing powder, supported by local teachers in the area larly on the community’s view of edu- as well as menstrual pads for women. who could see the benefi ts of the clin- cation. She says that parents in the ics fi rst-hand in the children they were community started to send their chil- Between 1992 and 1994 five clinics were established in the Karen State. Due to mili- teaching. Both health workers and dren to school in much greater num- tary attacks, none remain in their original teachers would work together to de- bers. Say Hae remembers one family locations. One was re-established in Pa velop school health programs. In addi- in particular. The father was arrested Hite and still operates today. tion, according to Dr. Cynthia, the clin- by the SPDC and subsequently disap- The idea of establishing civil ics became the centre of many peared, presumed dead. The mother clinics in Karen State came to fruition communities. As the community, in- became very ill soon after and was di- in 1992 when one of the Mae Tao Clin- cluding women’s groups, teachers and agnosed with breast cancer. She soon ic’s mobile medical health workers village leaders, became more closely died, leaving behind two children. The working in Dooplaya came to Dr. Cyn- involved and worked with the clinic clinic staff cared for these two children thia and asked her to set up a clinic in for the benefi t of their communities, and provided them with an education the area. The medic introduced her to the role of the clinics within these com- in the village. They then attended one the local health authority, and after munities expanded. of the migrant schools on the Thai side several discussions, they agreed to set Over the years, more health work- of the border, and recently they were up Cho Gali clinic. MTC eventually ers trained by MTC, who came from resettled in the USA. established fi ve civil clinics in Karen diverse ethnic backgrounds (including In 1997, the SPDC attacked Cho

24 | FROM RICE COOKER TO AUTOCLAVE Gali, and the surrounding areas, forc- Staffs of Cho Gali civil clinic in 1993. ing the entire village to ﬂ ee. The SPDC and DKBA currently control the area. Say Hae says she has returned once since they were forced to ﬂ ee and says that the clinic has been destroyed and there is no longer any health care for any villagers who returned to the area.

SA KHAN THIT:

According to May Soe, a Mae Tao Clinic medic who began working at Sa Khan Thit in 1995, this clinic mainly treated pregnant women and buildings are abandoned and de- traditional beliefs are still incorporated patients with malaria. In addition, stroyed. into community attitudes toward there was a refugee camp nearby on the health. Pa Lae Paw remembers that Thai side of the border that had no clin- some villagers had come to the clinic ic, and so staff would often travel there PA HITE: to get help for a pregnant woman who to treat people. May Soe says that had been sick for a week. Staff from many children were abandoned at the The clinic that is now based in Pa the clinic made the trip out to her vil- clinic and she remembers one case in Hite, in Karen State, has had many in- lage to render assistance. They ex- particular; a young boy who came to carnations. Prior to being located in Pa plained that she needed to go to the the clinic who had no parents. Clinic Hite, it was at different locations in the clinic for treatment or she would die. staff cared for him and sent him to surrounding area, but was attacked by Before she would go, she wanted to school, and he now works for MTC. the SPDC several times, and medics consult the spirits in the jungle. Know- The same day that Cho Gali was and villagers were forced to fl ee. Each ing she would die if she did not go, a attacked, Sa Khan Thit was also at- time the clinics were attacked they had medic hid in the jungle and, posing as a tacked by SPDC forces, but unlike Cho prior warning and were able to save spirit, told her that she must go. When Gali, clinic staff had prior warning and most of their supplies by hiding them she got to the clinic, she was treated for were able to fl ee to Thailand before in the jungle - although sometimes they malaria and given two blood transfu- fi ghting began. When they moved, were destroyed by elephants or other sions. The baby was born safe and they had to take the 11 abandoned chil- animals in the area. well and they are both still alive today. dren they were caring for with them. Prior to the establishment of the These days, the training for com- They spent three nights on the Thai clinic in the area, traditional beliefs re- munity health workers creates a formal side of the border, near Sa Khan Thit, garding medical practices were preva- integration of the two practices. For and then made the journey to Mae Tao lent; beliefs which were sometimes at example, certain traditional beliefs re- Clinic. May Soe has not been back to odds with western practices. The com- garding prevention and hygiene can be Sa Khan Thit since, but says that she munity now regards western health effective and are highlighted. The has heard that all the equipment and care in a more positive light; however, health workers learn how to comple- ment the services of traditional healers and work side by side with them. Pa Lae Paw says that she is unsure about the future of Pa Hite clinic, she says that, at least for now, the situation is stable. Back in 2001 the SPDC attacked the area and the medics had to fl ee, but Pa Lae Paw asserts that they were merely lucky that time as the KNLA protected the area and saved the clinic, adding that the security situation and the isolation of the clinic are some of the most diffi cult challenges Field visit to Ler Per Her civil clinic with supporters. they face.

FROM RICE COOKER TO AUTOCLAVE | 25 ment of separate departments, ultimately leading to better, standardized treatment of patients and the adoption of established protocols. After the expansion, the Medical OPD had a larger space with four separate exams rooms; three for seeing patients and one for administering medication. A mere six medics completed all of the renovation work. In 2000, the Medical OPD moved into a new building with six exam rooms, four for general care, one for chronic disease patients, and one for malaria cases. It is currently staffed by 12 full-time medics, but staff may number up to 35 when there are students doing their practical training. Two medics work together in each Medic examines patient. exam room, normally seeing only one patient at a time, but sometimes seeing two at a time if the department is over- MEDICAL OUTPATIENT whelmed with patients. In the first half of 2008, 81% of malaria DEPARTMENT patients with the most deadly strain (P. Falciparum) came from Burma. In the beginning all of the medi- patients and scope of services contin- cal services available at Mae Tao Clinic ued to increase, with the number of pa- A separate space to treat malaria were provided under one roof. Patients tients requiring specialized services patients has always been necessary at came to have a wide variety of ailments such as minor surgeries, obstetric and MTC, but a separate exam room to treated, ranging from treatment for ma- delivery services, and child services treat patients with chronic disease is a laria, to having wounds dressed to the beginning to overwhelm a single Med- newer development. The patient de- delivery of babies. Although many of ical OPD. In 1999 therefore, the MTC mographic is changing considerably, these patients stayed overnight, this is expanded to allow for the establish- with more and more patients crossing still considered the origin of the Medi- cal Outpatient Department (OPD). The Medic checks patient blood pressure. equipment and medical supplies at this time were scarce and food was limited and very simple. Despite the limited resources of the clinic, no one was ever turned away. Although the space was small, an effort was made to keep trauma and maternal health patients separate. The original space was an old house, with various improvements added as time and supplies allowed. Originally the clinic was only open from 9:00 a.m. until noon, but increased patient loads necessitated an expansion of operating hours to a timetable of 8:30 am until 4:00 p.m, Monday to Saturday. Of course emergency patients were also admitted on Sundays. As time went on, the number of

26 | FROM RICE COOKER TO AUTOCLAVE the border for health services as the A medic and an internatilnal volunteer state of health care continues to decline examining patient. in Burma. Moreover, as word of mouth continues to spread regarding the wide variety of free services at MTC, more people are willing to risk the journey in order to receive the potentially lifesav- ing services. At this point, MTC cannot fully treat most of the chronic disease cases that are presented such as diabetes, heart disease, and hypertension. Both the lack of resources and infrastructure to support the health care needs of long-term patients are issues yet to be overcome. Moreover, medics are not yet fully trained to cope with these illnesses, although they continually strive for that knowledge and work to gain it through weekly case studies, and upgrade training programs. It is a frustra- tion and a challenge for the medics when they cannot provide the proper have to maintain high levels of com- through pictures, making it much easi- treatment for a patient, but it is also a munication and ensure that communi- er for the patient. Not counting solely challenge when they can. cation with patients is also strong. on this method though, the pharmacy is The staff of the Medical OPD When patients speak a variety of dif- always staffed with 3-4 people who continually works to ensure that pa- ferent languages, and often cannot read can speak a variety of languages, en- tients take their prescribed medicines or write, this presents considerable ob- suring that patients are also be given properly. Unlike the other clinic de- stacles. In 2005, new medicine distri- the instructions verbally. partments, where patients receive their bution bags were created in order to Language barriers and illiteracy medication directly from the medic eliminate the need for a patient to be have also been a challenge when it caring for them, in the Medical OPD able to read. Since the implementation comes to educating patients about their the pharmacy is a separate unit. There- of these bags, the dosages and schedule illnesses. With Medical OPD continu- fore, the medics and the pharmacy staff for taking the medicines are depicted ally getting busier, the medics can only spend a small amount of time with each patient, and so the hope is to produce more printed education materials to Mae Tao Clinic Caseload give to patients. These printed materials however, need to be produced in 2007 2008 more languages and also need to take into account patients who cannot read Total visits 114842 140937 The staff of Medical OPD recog- Total caseloads 81747 95987 nizes that until there are radical chang- Total admission 9066 10980 es in the political situation in Burma, Delivery admission 2117 2467 MTC will continue to see an increase Referral admission (MSH) 786 886 in patients; the staff hopes for the nec- VCT test for HIV 931 1224 essary developments to be able to serve these patients. They need a larger wait- Malaria 5276 6681 ing area, more exam rooms, more med- Pulmonary Tuberculosis conﬁ rm 220 151 ics, further training and greater re- Prosthetics 186 219 sources to be able to recognize and treat the greater variety of illnesses coming through the door.

FROM RICE COOKER TO AUTOCLAVE | 27 then, MTC has performed blood transfusions, as they have been necessary for the large numbers of patients arriving at the clinic with anemia due to malaria, tuberculosis, nutritional defi ciency, chronic disease or blood loss due to complications of childbirth or surgery. Beginning in 2004, malaria and hemoglobin screening was provided for all pregnant women as well as children under 12 years old suffering from malnutrition. In the border area, malaria is one of the biggest health threats, with high prevalence, transmission rates and drug resistance. The border population tends to be very mobile in areas without permanent health care centers or electricity for laboratories. Where treatment did occur in these areas, it was through self-diagnosis or without any diagnosis. As the patient population grew so did the need for further laboratory ser- Taking haematocrit vices. Today the laboratory services include: LABORATORY AND BLOOD • screening for malaria and hepatitis • blood typing BANK • cross-matching for blood transfusions Since its inception in 1989, main Mae Sot Hospital. This wasn’t a • urine analysis for glucose levels laria has been the most common illness sustainable or cost-effective approach, • HIV rapid tests. presented at Mae Tao Clinic; thus it so in 2000, MTC with the support of HIV screening began in 2001, as made sense for the clinic to have labo- MSH, set up a blood donation centre an antenatal care service for pregnant ratory facilities with the ability to per- and blood bank for the blood transfu- women in collaboration with Mae Sot form malaria screening, rather than re- sions performed at the clinic. Since Hospital (MSH) on their Prevention of lying on an external laboratory. Laboratory work fi rst began at MTC in 1992, with a staff of approximately Malaria Slides Processed four tucked away in a small corner with 2 microscopes, and a freezer. The staff performed malaria screening, hemoglobin testing for anemia, and blood typing. In 1995, the clinic began blood donor screening on a case-by-case basis, but there was no storage facility for donations. In 1996, there were 36 transfusions, still using case-by-case screening, using mainly clinic staff as the donors. If there were no donors available, blood was purchased from MSH. In 1997 MTC began collecting blood from factory workers in order to keep suffi cient inventory and stored it

28 | FROM RICE COOKER TO AUTOCLAVE Mother to Child Transmission (PMTCT) program. In 2003, the Vol- Fixing the slide. untary Counseling and Testing (VCT) services began. In 2008, the PMTCT screening was ‘insourced’ to MTC which provided quicker results for improved post-test counseling and follow-up care, as well as lower costs. This led to the expansion into two lab rooms, along with separate HIV and malaria rooms. MTC Laboratory staff was given the opportunity to tour the MSH lab, blood donation centre, and blood bank facilities, learning the policies and procedures being utilized there, and receiving training for cross- matching donors to recipients.

BLOOD DONATION CENTER nate. This poses a challenge, as factory quality control protocols, with regular workers have very limited free time, internal and external controls per- The Blood Donation Center ser- with the entire process of risk assess- formed. Hsa K’Paw greatly appreci- vice at MTC now encompasses the col- ment and donation by up to 100 people ates and understands the benefi ts of lection, screening, storage and admin- having to be completed in a few hours. these collaborations, “We stand by our istration of over 1,000 units of blood This is also seen simultaneously as a protocol, but sometimes we need ideas each year. All donors are unpaid vol- valuable opportunity to provide donors from others. We have to share with unteers, with the safety of the blood with health education about transmis- other people and learn from other peo- supply ensured through the universal sible diseases, in particular, HIV and ple.” He also works to ensure that the screening (by MSH) of donated blood hepatitis. other laboratory staff understand this, for hepatitis B and C, HIV, syphilis and Laboratory Manager, Hsa K’Paw “I want them to understand everything, malaria. Most often donors are factory goes to great lengths to ensure the qual- to be able to do all the work in the lab, workers that come as a group to do- ity of the lab work. There are rigorous and know who to contact if they have a problem. To contact MSF, MSH, SMRU….I want the next generation to know members of other organizations.” Hsa K’Paw views the Laboratory Training program as an opportunity to share this information and insight beyond the clinic. Laboratory training participants come from various ethnic groups inside Burma and then return to their communities once the training is complete. Saw Hsa K’Paw lets the trainees know that he is available to help even after they fi nish the program, “They contact me if they have a problem. I am able to give them help, and ideas. I am proud to affect all of the regions of Burma.” It is this attitude that contributes to the lab having a much greater impact on border communities, making the many tests run each day Malaria microscopy. only a small part of the contribution. FROM RICE COOKER TO AUTOCLAVE | 29 Water and Sanitation staffs building MTC needed to improve existing a water supply system. waste-water management systems. The local community had been complaining about the run off from the clinic, and MTC wanted to maintain a positive relationship with the local authorities and community. Therefore, the construction and stabilization of ponds for waste water was undertaken. The clinic also concentrated on the reduction of vectors (mosquitoes) and vector-borne diseases by introducing vector eating fi sh into the pond, thus decreasing contamination in local ponds. These improved methods of WATER AND SANITATION waste water disposal proved valuable in enhancing the relationship between In the early years of Mae Tao Sanitation Department at MTC, water the clinic and the local community. Clinic, access to water was a major ob- and sanitation was a feature of the civil Today, with the continuing ex- stacle to the safe and effi cient running clinics run by MTC inside Karen State. pansion of the clinic, the role of the of the clinic. In addition, there was of- When the fi rst civil clinic, Cho Gali, department has grown, with responsi- ten overfl ow of waste water from the was set up, there were no toilets and bilities that include: toilets. In the monsoon season, this the area did not have a water supply; as • building maintenance (building overfl ow was particularly problematic a result, many of the children had and repairing), as it contaminated fresh water sites. In worms. The clinic worked to build in- • cleaning and repairing drains, the dry season, Mae Sot suffered se- frastructure for the local population, as • cleaning toilets, vere water shortages and many house- well as to educate them about how to • building additional toilets, holds in the local population had built use toilets and employ safe hygiene • sweeping and cleaning all outside water tanks in their homes to deal with practices. They also built school toi- areas, this problem. The clinic however, could lets and trained the children to use toi- • maintaining the horticultural as- not build permanent structures on the lets with water. pects of the clinic, site and thus had no water supply dur- The continued increase in aware- • controlling the clinic’s water sup- ing the day. The clinic water supply ness of water and sanitation issues lead ply would fl ow only in the evenings, and to the establishment of the Water and • recycling waste water to use in the this was when clinic staff did all their Sanitation Department at MTC in toilet and for cleaning the clinic’s cleaning; this included cleaning the 2000. Tin Htun, the department man- vehicles. medical instruments, having showers, ager, has been in charge of the program Tin Htun says that there have and cleaning clothes. This was usually since its commencement. Beginning been many challenges involved in run- done around midnight. with six staff members, the fi rst major ning the department. In the past it has effort was to increase the fresh water been a problem to build permanent One of the difficulties involved in running a water and sanitation program in the civil supply to the clinic. Even with rain structures on land that is only rented by clinic areas is that the pipelines can be water run-off, one deep water well and the clinic. Tin Htun adds that his staff trampled by elephants! a Thai pipe-line, there was not enough often faces blockages in the toilets, as In these nascent years of MTC, as water for the effective running of the many of the clinic’s patients are from the number of staff, staff families, and clinic. The clinic, in conjunction with rural areas, and have had no experience patients attending the clinic was steadi- the clinic’s landlord, applied to the using toilets. He says that they fi nd ly increasing, the lack of toilet facili- Thai government and was granted per- sticks or plastic blocking the toilets, ties became a major problem. The ex- mission for a larger pipe-line to go and sometimes patients go to the toilet isting toilets were over-used and often through the clinic. After the water sup- in the drains. When asked what he is would overfl ow. It was a health haz- ply issues had been addressed they be- most proud of regarding his work in ard, and there was a fear that the local gan to work on drainage, cleaning and the water and sanitation department, authority would shut down the clinic if the toilets; these were the fi rst priori- Tin Htun says that his greatest achieve- the problem was not addressed. Prior ties of the newly established department is implementing water recycling to the establishment of the Water and ment. because it is so useful to the clinic and In 2002, it was identifi ed that saves the clinic money.

30 | FROM RICE COOKER TO AUTOCLAVE PARTNERSHIPS: 1989 - 1994

Dr. Cynthia attends ﬁ rst international conference in Bangkok. Dr. Tom and Dr. Cynthia

When the MTC founders arrived in Mae Sot, they had no money, equipment, supplies, nor accommodation. Thank- fully, a number of local kind-hearted souls stepped in to help. Father Manat Supalak of the Mae Sot Catholic Church, and Monty Morris of Christ Church Thailand assisted in arranging safe accommodation, medicine, and food. They also assisting in fundraising, advocacy, and helping set up initial partnerships and connections with Mae Sot Hospital. Starting in 1992, Médecins Sans Frontières provided crucial in-kind donations of medicine which continued until 1997, along with assistance in setting up the laboratory.

PLANET CARE/GLOBAL HEALTH ACCESS PROGRAM

MTC has continued to strike a refugee medics Ben went on mobile balance for many years between re- missions into border villages cut off ceiving assistance from outside and from access to medical care by the war. maintaining itself as a sustainable in- Ben continued to go back to Mae Tao dependent community managed orga- Clinic twice each year, bringing sup- nization. One of the fi rst outside supplies and teaching valuable skills.” porters of the clinic was Ben Brown, Bob Condon was motivated by who found Dr. Cynthia with the help of Ben’s involvement and commitment a map sketched on a napkin in 1989. and got involved himself. He raised Staff recall, “He helped Dr. Cynthia money for the clinic, and recalls, who had recently fl ed Burma herself, “Thanks to many generous people treat sick villagers in a small wooden there was enough money to pay for the building with dirt fl oors, without medi- make-shift lab in an old two-story barn cal books or diagnostic tools except a in Mae Sot. That same barn still stands thermometer, a blood pressure cuff and at the entrance of the Mae Tao Clinic Dr. Ben Brown a stethoscope. With a small cadre of where Dr. Cynthia Maung continues to FROM RICE COOKER TO AUTOCLAVE | 31 run the clinic, offering free medical in my own way – which was to call vided the fi rst international volunteer services to thousands of displaced Bur- friends and ask for money”. administrator. This was the fi rst time – Bob Condon refl ecting on his history mese”. with the clinic. that international volunteers with critical skill sets were identifi ed and sup- “Ben [Brown] told me about Burmese refugees who fl ed over the border to a For many years, Planet Care ported by a stipend so that they could safe haven in Mae Sot, Thailand. Ben worked side by side with Global Health stay for long periods of time. In 2006 was headed back to Mae Sot with mi- and Access Program (GHAP). Planet GHAP and Planet Care merged, and croscopes, textbooks, and medical sup- Care brought medical teams of doctors continue to work today as an important plies so his Burmese friends could set up a temporary clinic to provide medi- and nurses who travelled along with partner of the clinic. cal care to other refugees. Ben’s pas- medics to civil clinics, and conducted sion to help inspired me to get involved training for medics. Planet Care pro-

Mr. Garry (BRC) at Kyaik Don 1992.

BURMESE RELIEF CENTER

Similar to Planet Care, Burmese tion system for the clinic, which they cilitated by BRC. They looked at clin- Relief Center is a partnership which collaborated with Planet Care. BRC ic capacity, public health needs, phar- spans the history of the clinic. The Bur- and InterPares set up an exchange with macy system, and clinic protocols. mese Relief Center (BRC) was set up, Philippines (psychosocial, health and While BRC has supported the in a similar fashion to MTC, as a re- human rights, reproductive rights) and physical needs of many refugees sponse to the thousands of Burmese Guatemala (women’s change). BRC through the years, they were instru- students who had fl ed the crackdown provided crucial assistance in building mental in fostering the community on the 1988 nationwide democracy up- the advocacy capabilities of the clinic based organizations activities. They rising and were staying in camps all – which are now a cornerstone of the have played an important role in advo- along the Thai-Burma border. BRC clinic’s work. cacy and community building activi- began to collect and distribute food, BRC also supported the fi rst clin- ties. BRC promotes the development medicine and clothing to the refugees ical internship program in 2002. Their of civil society organizations that will along the border. BRC staff recall, view was that MTC could not solve the provide the foundation of a democratic “My fi rst memory of the clinic is of a health problems on the border alone, future in Burma. InterPares explains, dingy wooden shack with rows of Bur- and the ethnic health workers needed “In these ways, BRC is helping to de- mese students in longyis lying on the to be trained and empowered to work fi ne what is possible for a future in fl oor with intravenous drips in their inside Burma. This internship program Burma that is just, democratic and arms”. BRC was the fi rst organisation continues today, with a high demand peaceful.”11 to provide ongoing grants to MTC in for seats in the course. Dr. Chris Beyer 1994, which were used for monthly and team conducted the fi rst external 11 “Working for Change Among Equals”, Inter- Pares 30th Anniversary Special Report, p. 5. running costs. BRC also assisted in evaluation of the clinic, which was fa- setting up the fi nancial and administra-

32 | FROM RICE COOKER TO AUTOCLAVE BRACKETT REFUGEE EDUCATION FUND “One day I sought a driver to take me from Mae Sot to the Clinic. My Thai was not Although the Brackett Refugee people”. After Brackett was founded, good enough to explain where I wanted to Education Fund (Brackett) was found- they started the school for Dr. Cynthia’s go. So we negotiated a price that he was ed in 1997, the staff had been person- children and children of the staff. willing to take in payment for a very long ride. It was much more than the short drive ally involved in the clinic since Janu- Brackett is understandably proud of was worth, but I was willing to pay because ary 1992. For example, Brackett this accomplishment – the original I had to get there. When the driver found produced the ﬁ rst annual report of the school has evolved to be the CDC to- out where I was actually going, he gave me clinic in 1995, and provided English day, with 1,000 students, from kinder- all the money back and refused to accept any money for his service. I like to think of that language and computer training for garten through to Grade 12. Today, as a testimony of the truly fine work Dr. staff. One Brackett staff member re- Brackett continues to provide support Cynthia and her staff has done from the very calls, “At that time it was a very small, for schools, medics, scholarships and beginning, and of the appreciation of some poor place. I can remember bringing a other areas of need for the internally Thai for her merit”. –Brackett staff member small bag of oranges to share with the displaced populations in Burma.

ALL BURMA STUDENTS DEMOCRATIC FRONT

ABSDF was formed in 1988 as a Dr. Cynthia and ABSDF students. response to the military crackdown in Burma, and worked in partnerships (al- beit sometimes uneasy) with the ethnic resistance groups. ABSDF worked in partnership with the clinic to deliver training and coordinate support to civil clinics. When Chogali and the other civil clinics were established, ABSDF students were pressed into service as medics. Whether they were previously medical students, doctors, or had no prior experience, the students learned on the job. KAREN DEPARTMENT OF HEALTH AND WELFARE When villages in Karen State were attacked or natural disasters occurred, the Karen Department of Health and Welfare (KDHW) has provided relief inside Burma. KDHW has worked in partnership with MTC since the early years, for example conducting the fi rst midwife training for mobile medics. In Dooplaya district, KDHW established a civil clinic, has been an MTC civil clinic partner in other areas, and works in Burma through its own Mobile Medical Teams. The fi rst formal training conducted by MTC was a midwife course taught in collaboration with BMA and KDHW. Naw Ree was the fi rst trainee participant and still works in MTC’s reproductive health department today. This training was conducted in Ah Zin KDHW’s fi rst health information seminor in Jungle. FROM RICE COOKER TO AUTOCLAVE | 33 Village (Dooplaya district) in 1992 at sist. KDHW worked with MTC to set formation Management Seminar in Paw Taw Moo Hospital with 50 par- up mobile medical teams and clinics Karen state. This seminar covered ser- ticipants. Since that time, KDHW which are described in more detail in vice delivery methods, establishing worked in collaboration on relief pro- subsequent chapters of this book. standards of care, and fostering com- grams, such as the fl ood in 1993 in KDHW has been a key partner of munity participation. KDHW invited Kyaik Dom . When Ah Zin village was MTC in supporting IDP populations CBOs and INGOs to coordinate health attacked by Burmese military in 1994, inside Burma. In 1996, MTC and programs in Karen state. MTC and KDHW joined forces to as- KDHW organized the fi rst Health In-

BURMA MEDICAL ASSOCIATION

Public Health and Human Rights (USA), Mae Tao Clinic, Global Health Access Program (USA), and local Bur- mese Health Organizations. The goals of the project include: improving access to essential maternal health interventions among vulnerable communities in eastern Burma, capacity building, delivering evidence-based maternal and newborn health care and providing information to inform service delivery strategies in similar settings. The target population for the pilot study was Advocacy trip to Australia. (left to right) Mis. Pippa (BRC), Nang 60,000.13 Chang Toung (SWAN), Dr. Cynthia Maung (MTC), Saw Nay Htoo (BMA), Dr. Vit (John Hopkins University) 2009. These days, BMA is supporting over 30 clinics, serving approximately How does it happen that a small community health education work- 200,000 people across six states in community-formed organization, ini- shops, HIV prevention education, and Burma. BMA serves eight different tially with no funding is eventually health education materials in appropri- ethnic areas in Burma, with a footprint cited in medical journals?12 The BMA ate languages. spanning the Thailand, India and China was founded in Karen State, Burma in In 2000, Dr. Cynthia became borders. The distance in kilometres is June 1991 by a group of medical pro- Chairperson of the BMA, which for- not necessarily the challenge, but rath- fessionals led by Dr. H. M. Singh from malized her and MTC’s role as a men- er, crossing through various security Burma. Although formed in the Karen tor and technical advisor to the group, checkpoints and unstable areas to the state, BMA was a collaboration of providing training and technical assis- reach the patient populations. many ethnic groups who were repre- tance for BMA. Starting in 2007, the The BMA, in coordination with sented in the Manerplaw stronghold. ‘push’ of improved funding and re- MTC, Ethnic Health Organization and The National Coalition Government of sources coupled with the ‘pull’ of the the Back Pack Health Worker Team, the Union of Burma took the initiative ever-increasing health needs of the IDP has coordinated a wide variety of ser- to coordinate and join forces across community in Burma, led to an ongo- vices including; training and curricu- ethnic groups to create BMA and to ing evolution of BMA towards becom- lum development for maternal and improve health care coordination in the ing a more rigorous and far reaching child health, training for traditional ethnic areas. The organization serves organization. Although Dr. H. M. birth attendants, school health, hygiene as a leading body in the coordination of Singh passed away in 2000, his legacy practices in medical settings, water and public health policy and promotion of lives on in the passionate desire of sanitation, malaria management, solar health care among refugees, migrants those working for the BMA to provide panel installation and maintenance, and IDPs from Burma. Since its incep- public health infrastructure in Burma. emergency obstetric care, health infor- tion, the BMA has provided medical To this end, the BMA has been the key mation and documentation and health and fi rst aid teaching to community partner in an innovative pilot program policy and system development activi- health workers, mobile medical teams, in the border area, Mobile Obstetric 13 “The MOM Project: Delivering Maternal Maternal Health Workers (MOM) Proj- Health Services among Internally Displaced 12 Mullany et al, “The MOM Project: Deliver- ect. The project involves collaboration Populations in Eastern Burma”, Mullany, Lee, et ing Maternal Health Services among Internally al, Reproductive health Matters 2008; 16(31): Displaced Populations in Eastern Burma”, Re- between Johns Hopkins Center for 44-56. http://www.jhsph.edu/humanrights/_pdf/ productive Health Matters, 2008; 16 (31) 44-56. Mullany_MOM.pdf 34 | FROM RICE COOKER TO AUTOCLAVE ties along the Thai-Burma border. These activities have been ongoing for over fi ve years in an effort to reduce maternal mortality and morbidity rates among women as well as to decrease prevalence of communicable diseases such as malaria and gastrointestinal tract infection for populations living along the Thai-Burma border. Since 2005, BMA has been running several projects on Reproductive and Child Health and has partnered with migrant and ethnic health organizations to increase access to reproductive health (RH) services and information. BMA’s work is not only focused on IDP areas in Burma. BMA one of the fi rst partners with MTC for school health promotion and HIV prevention education in the migrant areas of Thai- Water and Sanitation program in IDP area. land. This collaboration began in 1999, with MTC and Doctors of the World to nally displaced, migrant and refugee future challenges for BMA include: se- improve migrant health. This migrant communities in border areas, with a curing long term funding, attempting outreach program has grown, with oth- monthly circulation of 2,000. to keep up with the growing and unmet er CBO’s complementing these efforts BMA has evolved since its incep- health care needs of their patient popu- through collaboration. It is also nota- tion. Initially, the goals were focused lation, and managing the security of ble that this was the fi rst of many col- on coordination and friendship among health workers. BMA hopes to achieve laborations with the Thai Ministry of the health care workers and service increased access to maternal and child Health . providers in Burma. After a conference health services and reproductive health BMA also began publishing the in 2000, the goals became more fo- information and services. BMA will Nightingale Health Journal is 2003, cused on specifi c public health goals; continue to collaborate with MTC to which aims to promote an exchange of improving health information, delivery work towards international advocacy health-related knowledge among inter- and standards across ethnic areas. The to improve cross-border health care.

MAE SOT HOSPITAL MSH has continued to provide invalu- that go to MSH for a variety of treat- “Mae Tao Clinic has successfully been able support to the clinic – not only ments, including various surgical pro- providing health services to the migrant population which normally has poor ac- providing medical treatment and stan- cedures and caesarean delivery. For cess to health care. We have been work- dardized records, but also training each of those patients there might be ing and supporting each other to reduce staff, donating supplies, and aiding twenty hospital visits, so the referral the health burden in the population since with laboratory quality control. staff and Mae Sot Hospital can be very the establishment of the clinic. The cooperation between the clinic and the Mae Sot The medical referral program that busy! General Hospital has long been excel- started in 1989 was initiated and sup- In 1995, the clinic introduced a lent.” ported by Father Manat Supalak and blood transfusion program. MSH – Dr. Kanoknart Pisuttakoon, Director local Catholic Church organizations. helped with the development and nec- Mae Sot Hospital This included patient transfer and food essary training of staff, and also Since its beginnings in 1989, Mae support. The most common referrals in screened the donor blood that was col- Tao Clinic has had a strong collabora- the beginning were severe malaria cas- lected by MTC, collected the blood of tive relationship with Mae Sot Hospital es which required transfusions. Today some donors that the clinic arranged to (MSH). Initially, the clinic was able to the clinic is able to treat malaria cases, go directly to MSH, and even provided do little more than dress minor wounds although if the patients progress to re- blood if the clinic did not have enough. and treat simple malaria and all severe nal failure they are referred. These The clinic stored blood at MSH from cases were referred to MSH for treat- days, there are still approximately 60 1996 until 1998. Today the clinic re- ment. Throughout the last 20 years, patient referral admissions per month ceives enough blood donations, but

FROM RICE COOKER TO AUTOCLAVE | 35 nication between the groups through regular information exchanges, and improvement and standardization of care being offered to the migrant community, through the development of screening is still conducted by MSH, Vaccination Cards and Ante-Natal with MSH in implementing expanded with 1,696 donors screened in 2008. Cards, as well as joint interventions by access to Antiretroviral treatment14. 1995 also saw the beginnings of mater- the organizations. MTC provides the initial counselling nal and child health services at the Ultimately, this work led to the and testing service, and then if a patient clinic. MSH began supporting these introduction of the Migrant Health is identiﬁ ed as positive, the MSH can services through the donation of vac- Program by the Thai Ministry of Health provide ARV. The patient must meet a cinations for children under ﬁ ve years (MoH) in 2000. In response to this, list of criteria, with the clinic guaran- old, tetanus vaccinations for pregnant MTC appointed a Migrant Health Co- teeing compliance. Patients who live women, and family planning supplies ordinator to work with the MoH. This in Burma or don’t satisfy certain clini- such as Depo-Provera and birth control resulted in an increase in out-reach ser- cal criteria do not enter the program, pills; support which continues today. vices for MTC, including HIV educa- which currently has 48 patients. Besides donating supplies and tion, and a School Health program. A In response to research on post- equipment, MSH has also helped fa- Traditional Midwife Training program abortion services for migrant women, cilitate the ordering of equipment and was started, which yielded a greatly conducted at both MTC and MSH, the supplies through medical companies in improved home-delivery service and two health care facilities began work- Bangkok, as the clinic originally did strengthened the emergency obstetric ing together on the Post-Abortion Care not have the capacity to do this on its referral system. Quality Improvement project, in coor- own. Also in support of the new ma- HIV is one example of a public dination with Darwin University, Aus- ternal and child health services, MSH health issue best addressed by utilizing tralia. Due to language and cultural provided free referrals in 1996, includ- partnerships. As discussed in greater barriers it was decided that the clinic ing treatment of pregnant women with detail in the HIV chapter, MTC has would have three staff members work malaria, and tubal ligation surgery. As been working with MSH since 2001 in at MSH to provide counselling and the program, and thus the number and the HIV area. In 2001, MTC joined as education on abortions. Currently, any types of referrals increased, the clinic a partner in the Perinatal HIV Preven- Burmese women admitted to MSH for began paying for these referrals, but tion trial. This subsequently developed post-abortion care, even when not re- MSH still allows case-by-case negotia- into the Preventing Mother to Child ferred by MTC, receive counselling tion, and at times provides discounted Transmission (PMTCT) programme at and follow-up care by MTC staff. Ser- fees. the conclusion of the trial. As part of vices and procedures were also up- In 1996, MSH invited clinic staff this program, the clinic conducts HIV graded at both facilities, with manual to attend trainings in the Public Health counselling and testing, and if the vacuum aspirations introduced at Communicable Disease program. To- mother tests positive she delivers her MSH, due to the fact that they are less gether with the World Vision Founda- baby at MSH, with all appropriate painful and incorporate less risk for pa- tion, MSH organized the Meeting of medication for transmission prevention tients (these have been conducted at Organizations Working for Migrant supplied. Both MSH and MTC then MTC since 2004). Workers in Mae Sot, in February 1998. provide ongoing support until the baby Considering that MTC is not a le- Even though there was no national pol- is 18 months, with support including gally recognized establishment in icy for migrant health, the local health milk powder, psychosocial support, Thailand, the level of support it has re- organizations saw the need to have a and home-based care kits. ceived from MSH and the MoH is re- better-coordinated effort for providing The Medical Waste Disposal markable. The local support provides health care services to the migrant pop- partnership between MTC and MSH a certain amount of stability, and thus ulation. MTC was one of several at- began in 2001. Previously the clinic the ability to work effectively. The sup- tending organizations. As a result of had buried placentas and discarded port goes beyond MTC, to include this and subsequent meetings, work blood at the back of the clinic property, 14 Migrant Extension of Thailand’s National began towards ensuring better commu- but with more and more patients the Access to Antiretroviral Program for People Liv- clinic simply lacked the capacity to ing with HIV/AIDS – Extension (NAPHA) continue this method of disposal. Now, all needles, syringes, human tissues, expired blood, and infected blood are taken to MSH at 6:00 am every morning. In 2007 MTC began collaborating

36 | FROM RICE COOKER TO AUTOCLAVE many other health CBOs in the area, Mae Sot Hospital’s director and MTC staffs. allowing those organizations to provide greater community outreach services. This support from the local Thai community has helped strengthen partnerships between the local health organizations, and in particular, has resulted in improved access to the Thai health system. Inside Burma it is impossible to form this type of relationship; CBOs not sanctioned by the junta simply do not exist, resulting in a major gap in health services. When the junta intro- duces a major health campaign, such as the 3-Disease Fund, which provides free medications for malaria, tuberculosis, and HIV, the campaign usually only supports the medication but not ed patients eventually arrive at Mae sees the relationship between Mae Tao the social services (counselling) or di- Tao Clinic, adding to the already bur- Clinic and Mae Sot Hospital as a para- agnostic costs, such as diagnostic x- geoning caseload. digm, “This is a model for how a mi- rays, blood tests or sputum tests. Due In Mae Sot, effective public-pri- grant or vulnerable population can be to the fact that these costs are not sup- vate partnerships between Mae Tao supported. This is the example of the ported by the junta, the ﬁ nancial bur- Clinic and Mae Sot Hospital, among relationship that should exist between den falls on the patients. Further there others, is in stark contrast to the situa- the government and CBOs. It is no community support system for tion in Burma and has allowed for improve[s] coordination and improve[s] these patients whereas in Thailand the treatment for many patients unable to access to health care service.” Dr. Thai Ministry of Health fosters social access the Burmese public health care Cynthia hopes that the international support services delivery for these pa- system. MTC is able to support these community will learn from this exam- tients. Therefore, the vast majority of patients with counselling, testing, and ple and that health practitioners are the civilian population inside Burma follow-up support while the MSH sup- able to glean a better understanding of who cannot afford to cover these costs ports the medications; the two compli- the role of CBOs and how to work ef- goes untreated. Many of these untreat- ment each other very well. Dr. Cynthia fectively with them.

FROM RICE COOKER TO AUTOCLAVE | 37 38 | FROM RICE COOKER TO AUTOCLAVE 1995 – 1999: GETTING ORGANIZED

Medic checks a pregnant woman’s blood pressure at Reproductive Health OPD (photo: James Mackay, www.enigmaimages.net)

FROM RICE COOKER TO AUTOCLAVE | 39 “A LAND OF WAR: A JOURNEY OF THE HEART” I HAD VISITED Chogali village the border as "Dr. Cynthia." She ran a an article on mutual funds. so often, in stray moments, it some- clinic there, took in orphans and trained Suddenly, I was back in Chogali. times seemed I never left. In reality, medics to care for hill-tribe people who This time, I was surrounded by artil- almost a year had passed since my hus- had no other access to modern health lery, exploding bamboo, snakes wrig- band and I volunteered in medical clin- care. gling in the heat, ash settling on empty ics along the Thai-Burma border. That such a gentle community huts. At least I hoped they were empty. We took many snapshots, but I could exist in the middle of war be- I hoped the village people had all es- didn't need them to travel back -- down came my antidote to the world's hor- caped, scattered into the jungle. I re- the rutted elephant trail, across the rors. called a human-rights documentary in steppingstones in the stream, past the After we came home to Seattle which a former Burmese soldier, in black pig in the bamboo pen, along the last summer, I kept returning, in my tears, admitted raping village girls. path lined with white star fl owers that mind, to Chogali. To escape from the I thought I saw the little orchid smell like magic. blur of news of war, of genocide, of girls hiding in a grove of banana fronds. This is how I liked to remember rape, of hunger and hate . . . . I felt relieved they were malnourished, Chogali, as a place of little girls and I'd hear a snippet, read a headline, too light to crunch the bamboo leaves orchids, of peace and hope. then drift away to be with the little or- underfoot. Actually, Chogali was -- and is -- chid girls, mixing mud and rain in co- I hoped they were together. I in the middle of a war. conut shells -- playing pretend within a hoped the soldiers would not fi nd them. On one side is a military dictator- game of pretend. I wondered if they were cold. ship that in the past 35 years has killed, Then Chogali fell. I wondered what I could do. tortured and displaced millions. On the The message came over the Inter- I turned to the only thing I know other are ethnic tribes who want au- net one morning last February, a few how to do: I dug out my passport and tonomy and dissidents who want de- sips into my fi rst cup of tea: went back to the Thai-Burma border, mocracy. "Burmese Relief Center -- Japan this time as a reporter. The military is winning. Burma's has just received information SLORC I realized the war in Burma might people have lost just about everything (the Burmese military) occupied Cho- seem as distant to most readers in Se- that makes life decent. And every year, gali yesterday morning." attle as it once did to me -- just another things get worse. As I read it, the little girls ap- of the many confounding "ethnic con- In this country of chaos, Chogali peared again, shoulders hunched, fl icts" smoldering around the globe as was an oasis. The village was nurtured scared. I wandered around the news- the century closes. Bosnia, Rwanda, by a remarkable woman known along room, unsure if I could fi nish writing Chechnya, Congo, Cambodia -- news

40 | FROM RICE COOKER TO AUTOCLAVE we struggle to understand, news we struggle to ignore. The problem isn't that we don't care. We're rarely given the chance. Most of our news about war is dominated by quotes from pundits, de- bate about economic sanctions, dis- patches on the latest counteroffensive. But war is not only about weaponry and economics and aging generals grasping for more power. War is about little girls playing in a village. I returned to the Thai-Burma border as a journalist, but I wanted to write a story of the heart. I longed to fi nd those two little not what I had expected. told me, "but everywhere I see the men orchid girls. They were real. They I had imagined, before we ar- go off to fi ght or get captured, and the haunted me. I needed to know what rived, that we would see battle wounds women and children suffer most." war had done to them, what it was do- like in "M*A*S*H," when the theme Dr. Cynthia has done much to re- ing to me, what it can do to us all. music plays and the choppers swoop duce that suffering. In addition to the Secretly, I hoped I might save down and the medics crouch low under main clinic at Mae Sot, she ran a half- them. rotor blades, carrying moaning men on dozen smaller fi eld clinics in jungle WE HAD FIRST HEARD about stretchers. I had expected cowboy sur- villages across the border in Burma -- Cynthia Maung at a party on a rainy geons extracting shrapnel, nurses hold- including Chogali. Seattle night in fall 1995. A public-ra- ing gauze over land-mine stumps, le- When we visited last year, Cho- dio reporter had told us about a young gions of muddy army boots. This was gali had 29 babies, 56 other children, Burmese doctor, herself a refugee, who war, wasn't it? 148 adults, 60 bamboo houses, fi ve el- ran clinics on the Thai-Burma border. In the slow heat of the fi rst morn- ephants, one microscope, no electricity Mother Teresa to Burmese refu- ing, I kept waiting for the arrival of and no cars. gees... in her 30s... fl ed Burma after the bloody soldiers but kept seeing more Gurgling blue PVC pipes Dr. 1988 military crackdown... main clinic and more women. Pregnant women. Cynthia had installed to divert clean in Thailand... several thatched-hut clin- Women shivering with malaria. Wom- water from upstream meant the women ics in rebel-controlled Burma... Every- en coughing from tuberculosis. Women didn't have to spend three hours a day body calls her, simply, Dr. Cynthia. bent over from diarrhea. Factory girls hauling water in oil cans while the men My husband, Tao, had fi nished with ugly rashes on their legs and gash- were gone. his pediatric residency -- four years of es on their hands. Emaciated ladies The teak-leaf nursery school she life as a tired blur -- and we wanted to with glazed yellow eyes. had built fed the children one good have an adventure, do something Every so often, a rickety blue meal a day, monitored their vision and hands-on. In March 1996, we landed at pickup loaded with garlic and bananas growth, screened for worms, immu- Dr. Cynthia's main clinic in Mae Sot, skittered off the road where the pave- nized. Thailand, a dusty town about a 20-min- ment crumbled into dirt. Out jumped The latex squat latrines she had ute jog from the Burma border. For the children, their scrawny brown legs installed helped dry up dysentery and next three months, Tao would see pa- covered with mosquito bites. Then a cholera. The training she gave mid- tients and teach pediatrics, while I small parade of tired women unfolded wives meant fewer mothers and babies would peel mountains of garlic, lead a from the back of the truck and shuffl ed died from infection. Her clinic treated dawn aerobics class and type Dr. Cyn- into the clinic, leaving fl ip-fl ops at the malaria and malnutrition and snake thia's fi eld reports and grant applica- door. By noon, the concrete stoop was bites. tions. covered with fl ip-fl ops, mismatched, The little orchid girls had seemed The tin-roof clinic sits on the dusty, smudged under the toes. No safe, playing with tiny white blos- edge of parched rice paddies in Thai- army boots. soms. land's hottest province. The air smelled Finally, I realized, this was it. I do not mean to romanticize what of blood and iodine, sewage and steam- This was war: waged by men, dumped was, essentially, a harsh subsistence. I ing rice. Everywhere, there were fuzzy in the laps of women. just want you to know what was lost. chicks, suckling kittens, nursing moms. "I didn't have much idea about The place oozed with fertility. This was war before I came here," Dr. Cynthia by: Paula Bock, Seattle Times 1997

FROM RICE COOKER TO AUTOCLAVE | 41 such diverse ethnic, political and historical backgrounds comes together. Furthermore, although progress has been made, it is estimated that less the 30% of the migrant children between ages 5-18 are actually attending school. Efforts are being undertaken to make education even more accessible, with some organizations trying to introduce a night school program for students who are forced to work throughout the day, most often in agricultural work. There are also current initiatives to make the Thai education system more accessible to migrant school kids and to achieve closer integration between the Thai and migrant programs. The Thai Ministry of Education is working with BMWEC on an inclusive educa- CHILD PROTECTION tion program with activities including standardizing curriculum for primary SERVICES schools, training teachers and research on improving access to the Thai educa- MTC opened one of the fi rst day formation sharing and capacity build- tion system. care centres in the Mae Sot Area in ing programs for migrant teachers. In Even children who cross the bor- 1995. As the children continued to July 2000 the group changed its name der with their parents often end up in grow, the next obvious step was the de- to the Burmese Migrant Workers Edu- boarding facilities. The parents often velopment of a primary school; thus cation Committee (BMWEC), and the do not fi nd full time employment, and began MTC’s Children’s Development group began working tirelessly on even if they do, the wages are so low Center in 1998, one of the many mi- fundraising, advocacy, capacity build- that they can barely afford to feed their grant schools that would open in the ing, and curriculum development. The family let alone send their children to Mae Sot area. increased level of coordination and school. If the parent is lucky enough to standardization of services has lead to Burma ranks fi fth worst in the world on fi nd full time employment it often education spending at 1.2% of GDP. 15 stronger programming, with the com- means that they stay at the factory or munity showing a greater sense of farm where they are working, with the Some parents also wished to send ownership in the education system. boss requiring the children to begin their children to Thai schools, but were There have certainly been chal- working as soon as they are able. Par- faced with diffi culties when they lenges; work continues in standardiz- ents realize that sending their children couldn’t provide supporting birth reg- ing the curriculum used among the mi- to a boarding facility will ensure ac- istration documents for their children. grant schools, a very diffi cult task cess to an education as well as three In response to this, as well as to ad- when a community of people from meals a day for their child and safety dress the issues of statelessness, teachers, health workers, and other concerned individuals worked on raising awareness and assisted with establishing documentation for migrant children. Until 2000 there were no formal meetings between the migrant schools, but in April 2000 that changed when thirteen schools came together to form the Burmese Migrant Education Work- ing Group, through which there were regular meetings revolving around in-

15 CIA World Factbook, 2009. 42 | FROM RICE COOKER TO AUTOCLAVE from child labor. In response to major increases in the number of boarding children, the organizations working with education and boarding facilities in the Mae Sot area began a collaborative response through the development of the Coor- dination Team for Displaced Children’s Education (CTDCE). With three working groups: the Boarding House Work- ing Group, the Education Working Group, and the School Health Working Group, the CTCDE works to provide emergency food assistance to boarding houses, as well as develop a registration system for boarding children, child protection policies, and standards of care for boarding houses. With so many concerned individ- system, and providing students with have come as a stop-over before reset- uals and organizations coming together the necessary life-skills to prosper tling in a third country. Staff turnover to address the challenges of child within the community (as the majority continues to be a major problem among rights, education and security, progress of students will not have the opportu- the migrant schools. can certainly be seen, but challenges nity to attend formal post-secondary Of course, none of these chal- still lie ahead. Many of the children education). With so many disparate lenges will put a stop to the tremendous suffer from psychosocial illness – they considerations, the development of a efforts being made by the community; have come from confl ict zones and standardized curriculum has been far it is a community of people which have often witnessed or experienced from easy. seeks to foster strength, hope, and great violence and human rights abus- The diversity of the teacher popu- knowledge in the future generations. es. Work is being done to support these lation is also a challenge; these are in- Dr. Cynthia puts it simply, “working children, to provide them with tools for dividuals with various levels of train- on child protection is a collaborative stress management and to appropriate- ing, who come from different ethnic effort,” and this strong partnership be- ly deal with confl ict, helping them to groups, political backgrounds, up- tween the Thai and Burmese commu- be part of a diverse community and to bringings and ultimately, with different nities means that work will continue participate in the healing of the com- understandings of the situation in Bur- towards ensuring the rights, safety, munity. ma. Furthermore, these individuals growth and development of the chil- The diversity of the border popu- have come to the border with different dren on the border. lation is certainly a celebrated concept goals; some have come to stay, some at MTC, with the slogan “unity in diversity” seen throughout the community, on posters and the backs of t- shirts, but this diversity also imposes challenges. Curriculum development for such a diverse collection of ethnic groups living in a Thai community has been a particularly diffi cult challenge. It is a community that that wishes to be integrated into whilst simultaneously maintaining a sense of identity and culture. The curriculum providers have also been faced with the problems of which languages should be taught, what history, which political views? Moreover, there is the challenge of fi nding a balance between the strong academic focus of the Thai education Some working group member of Child Protection Service.

FROM RICE COOKER TO AUTOCLAVE | 43 DELIVERY CERTIFICATES AND CHILD DOCUMENTATION “In the beginning, we didn’t think stemming from the statelessness of about the delivery certifi cate and just children who were not offi cially recog- helped [patients] deliver here, because nized by any government. An update we had never thought that we would be to the delivery certifi cates was made in here for that long. After a few years, 2001 after it was decided that the infor- when these children entered the mation provided in the 1994 delivery schools, the problem started and the re- certifi cate lacked suffi cient detail. sponsibility was put our shoulders,” In 2003 MTC collaborated in the says Naw Htoo, one of the clinic’s establishment of the Committee for the founders. Naw Htoo refers here to the Protection and Promotion of Child problem Burmese children faced when Rights (CPPCR) . Collaborative meet- trying to access the Thai education sys- ings were then held with CPPCR, other tem; in order to attend school they CBOs, Burma Lawyers Council, and needed a birth certifi cate showing that the Thai Lawyers Society, to further they had been born in Thailand. In discuss the documentation of the Bur- 1994 MTC began issuing delivery cer- mese children. The results came in the tifi cates to all children born at the clin- form of two types of documentation ic in an attempt to address this prob- for children: the Birth Registration Re- lem. Although not offi cial birth cord, for children who already have a booklet is a record of all the mother’s certifi cates, they provide enough infor- delivery certifi cate from any hospital maternal health care visits. Although mation and authority for children to ac- (whether in Thailand or Burma) and the use of these booklets is a more in- cess the schools. The cards were also babies who are presented to CPPCR volved process, the benefi ts are worth part of an attempt to address the issues within 15 days of birth. The second it. Not only do the booklets provide a type is the Child Record, for all chil- more complete record of the health dren under 15 years of age who do not care that a women has received possess any form of documentation. throughout pregnancy, they also allow Today CPPCR works not only on reg- Burmese migrants, for the fi rst time, to istration, but also on child rights advo- apply for offi cial Thai Birth Registra- cacy, coordinating and participating in tion Certifi cates for their children born many child rights and child protection in Thailand. The RH-IPD hopes to campaign activities, such as the World train more staff in the processes of ap- Children’s Prize for the Rights of the plying for the Thai Birth Registration Child voting events, and International Certifi cates, as well as implement a Children’s Day. follow-up program to determine how MTC continued to issue its own many families successfully acquire the delivery certifi cates until July 2008, at certifi cates. With no immediate change which point a new collaboration was foreseen in Burma, the importance of established with the Thai Ministry of these certifi cates only increases, espe- Health; the staff of MTC are now au- cially considering the signifi cant rise in thorized to record births in the ‘Mater- the annual number of births at MTC – nal and Child Health Booklet’ distrib- from less than 20 deliveries in 1989 to Medics care for newborn uted by the Thai government. This nearly 2,400 in 2008. BAMBOO CHILDREN’S HOME MTC has responded not only to workers and teachers often ended up at MTC, and were then moved to Kway the needs of the children living on the caring for these children, with the clin- Kaloke refugee camp where they were Thai side of the border, but also to ic also functioning as a boarding facil- cared for by MTC staff in the Bamboo those of the children living inside Bur- ity. When these clinics were attacked Children’s Home (BCH). BCH has ma. At MTC’s civil clinics in Sah and evacuated in 1997, 10-20 children since been moved to Umpiem refugee Khan Tit and Cho Gali, the staff often from each clinic were brought to Thai- camp, but continues to be supported by saw children who had been orphaned land under the continued care of the MTC. by war or illness, and thus, health staff. The children spent a brief period BCH began with 3 staff and 49

44 | FROM RICE COOKER TO AUTOCLAVE children, all of whom were Karen; by BCH’s children and some donors, 2002. 2008 there were 16 staff members, and 154 children from various ethnic groups. The boarding house continues to see an increase in the number of unaccompanied adolescents coming from Burma in order to access education beyond the primary level. Each year, many children complete their studies and leave the BCH to pursue their cho- sen careers; some examples have included those working as medics, as administrators at MTC, or as teachers at the CDC. The satisfaction, former boarding house master Tin Htun says, is seeing the children fi nish their studies at the BCH and then go on to contribute to the peace and development of their community. the support and access to education. discuss any concerns they may have. Like so many boarding facilities, Win Tin explains that this is always Although these students are fortunate BCH struggles with enforcing rules harder done than said, as often the chil- to meet with their family members, it is among its students; when a student dren have no parents and nowhere else still incredibly diffi cult on their emo- breaks policy, showing little interest in to go. For the students who do have tional and mental health; this is a rec- education and failing tests, the policy one or more living parents, BCH tries ognized problem and to this end the is to remove them from the boarding to arrange monthly visitations at BCH, BCH works hard to provide strong house, making room for another stu- allowing parents to see their children psychosocial support to all of its student that would greatly benefi t from as well as meet with the BCH staff and dents. THE CHILDREN’S DEVELOPMENT CENTER CDC students in a class. house across the highway from the clinic, providing more space for both work and play for the students. Al- though not offi cial in the beginning, the CDC was already acting as a boarding facility as well, caring for 10 children by 1999. The next major challenge came as these children completed primary level schooling, and thus a separate high school was established in 2005, with 2009 seeing the fi rst grade 12 graduating class. In 2009, a new school facility was inaugurated with all the children from primary to grade 12 in the same facility. The 2009/2010 academic year has nearly 1,000 students enrolled, with approximately 50% of students being cared for in boarding fa- Like the other migrant workers in Care program was started, initially car- cilities. Between the school and the the Mae Sot area who were settling and ing for approximately 20 children. The boarding facilities there are 80 staff starting families, by 1995 the staff of next logical step was a primary school members performing all duties. Cur- MTC also found themselves needing and so the Children’s Development rently the CDC offers a wide variety of day-care services for their own chil- Center was established in 1997, with 5 classes including: Thai, Burmese, Eng- dren. As a solution the MTC Nursery staff members. This was located in a lish, Mathematics, Chemistry, Physics,

FROM RICE COOKER TO AUTOCLAVE | 45 Economics, Geography, History, So- will continue with the BMWEC and ing sure it continues to be the most rel- cial Studies, Community Development the Thai Ministry of Education to con- evant and beneﬁ cial one available for and Computer Skills. Coordination tinually evaluate the curriculum, mak- the students.

EMERGENCY DRY FOOD PROGRAM

Monthly Food Rations: per one child the lunches before coming to school. ther fund raising to ensure that they can meet the needs of the growing student Rice 12 kilo Work began in an effort to ensure that no student was missing school due to a population. In the interim at least, the Cooking oil 1 liter lack of food. dry food is a viable option as a long- Salt 1 pack The Emergency Dry Food Pro- term food program, even though it is Sardines 2 tins gram is one of the CTDCE Boarding not an optimal solution. The working Dried beans 0.5 kilo House Working Group’s programs, re- group will also work to develop stron- Total cost: 350 baht, $10 sponding to the food crisis at boarding ger monitoring and evaluation process- houses not only in the Mae Sot area but es for the program. BHWC member Food security is a major threat to also in IDP areas and refugee camps. and CDC teacher Eh Moo Paw high- the health and safety of the population Although it is understood that meat lights the ongoing dilemma facing the living along the border, especially for and vegetables are required for a community; although boarding facili- children whose parents cannot afford healthy diet, the drastic increase in the ties have reached their limits, one can- to feed them. In migrant schools it was number of children in boarding facili- not simply close one’s eyes and ears to noticed that children were often absent ties means that, at this point, the food the children that continue to cross the from school as their parents were un- program budget can only cover the cost border unaccompanied in order to ac- able to supply them with a boxed- of dry food rations. cess an education. lunch, or were providing lunch but no The immediate focus for the breakfast, and so children were eating Boarding House Working Group is fur-

46 | FROM RICE COOKER TO AUTOCLAVE schools, villages, and camps in Thai- land and across the border in Burma. In total, the eye clinic has trained nearly 1,000 health care workers who can be found working in all refugee camps and in nearly all ethnic states inside Burma. As part of the health outreach work done at MTC, the Eye Clinic promotes prevention methods throughout the migrant schools. On the Thailand- Burma border, as in many developing countries, vitamin-A deﬁ ciency from malnutrition is the number one cause of blindness in children. Periodic vitamin-A supplements not only help prevent blindness, they also enable children to better resist lower respiratory infections.

Graduated lenes at Eye department. • Approximately 87% of visually impaired people live in developing countries. EYE CLINIC • Globally, about 85% of visual impair- ment and 75% of blindness could be prevented or cured.17 Since the mid-1990s, the Mae few instruments and were often short Tao Eye Clinic has: of glasses with optical power high In 1997, the Eye Clinic began fa- • Facilitated more than 2,000 enough for patients with poor vision, cilitating on-site eye surgery in part- eye surgeries to restore sight lost most- according to Aung Phy, one of the orig- nership with the KarenAid surgical ly due to cataracts and glaucoma, the inal eye medics. The team persevered team from the United Kingdom under world’s leading causes of blindness however, and by the end of 1996, the the auspices of the International Res- • Trained almost 1,000 health eye care medics saw more than 30 pa- cue Committee. Initially, the team vis- workers in basic eye care and eyeglass tients daily and started an outreach ited the clinic for one week each year, refraction program in Karen State (later discon- performing at least 10 surgeries per • Conducted periodic eye tinued for security reasons). visit. Now, the team visits the clinic screenings for more than 5,500 chil- Over the next 14 years, the Eye three times a year and performs 400 to dren in 58 migrant schools and provid- Clinic’s services expanded signifi cant- 500 surgeries annually, mostly for ed vitamin-A in conjunction with the ly. In addition to its original services glaucoma and cataracts. These surger- Mae Tao Clinic School Health Pro- the Eye Clinic now facilitates eye sur- ies are invaluable; many blind people gram. gery for cataracts and glaucoma; con- arrive for surgery almost totally reliant • Dispensed more than 60,000 ducts eye screenings and eye-health on others, and come out of surgery with pairs of eyeglasses training for teachers in migrant schools; their independence restored. “If you • Dispensed 30 artifi cial pros- treats eye infections such as trachoma are blind,” says Aung Phy, “the only thetic eyeballs for patients blinded by (the leading infectious cause of blind- way of life is staying home, only eating eye infections and landmine-related ness in the world), and runs mobile and sleeping. You cannot do anything, eye injuries eye-health outreach in Thailand’s Mae you cannot go anywhere by yourself.” The Mae Tao Eye Clinic started La District.16 The patients come from nearby facto- in 1995 in an open-air bamboo shed. The Mae Tao Eye clinic has also ries, farms and refugee camps as well There, the fi rst group of three eye care become a base for eye training. It fa- as from inside Burma, from mountain medics began doing eye exams, man- cilitates eye health training as well as villages and cities as far away as Man- aging basic eye diseases, and refract- primary eye care training for nurses, dalay. Most have cataracts or glauco- ing and dispensing donated eyeglasses interns, health assistants, backpack ma, but others have been blinded by after being trained by the Border Eye medics, teachers and community health accidents; landmines, illness, infection Program. It was a modest beginning, workers who see patients in clinics, or inappropriate applications of tradi- with the medics initially seeing three to 16 World Health Organization, Fact Sheet 282, 17 World Health Organization, Fact Sheet No. fi ve patients a day. They worked with May 2009. 282, May 2009. FROM RICE COOKER TO AUTOCLAVE | 47 tional medicines. In 2007, 87.5 percent of the more than 500 surgeries were for cataracts, and 72.5 percent of patients came from Burma, mostly from Karen State. The incredible impact that these surgeries have on the patients is evident in the fact that simply through word of mouth, each round of surgeries sees a longer queue of patients. Weeks before the surgery team arrives at MTC, hundreds of visually impaired patients begin arriving at the clinic grounds. Many require the assistance of a family member or friend; all are hopeful of receiving surgery that could restore their vision. Although the surgery is provided free to the patients, it can still pose fi nancial diffi - culty. Most of the patients or their families must borrow the money or sell an Vision screening. animal to pay for transportation to the clinic. In recent years, so many people the surgical team only had enough time eye clinic program manager, one clini- have come seeking surgery that the to operate on approximately two thirds cal supervisor, one optometrist, and clinic hasn’t had enough space to house of them. Patients journey from so far several community health workers and everyone. Patients and their families and have so much at stake, the eye community health volunteers. As in have had to sleep in storage rooms, the medics say, that it’s heartbreaking to other departments, the resettlement of janitor’s closet, and outside under trees. see their hopes dashed. senior eye medics to other countries For a few weeks, the grounds are Unfortunately not all patients can continues to be a challenge. Their crowded, yet friendly, as if the clinic be helped. Their vision loss may have years of training and experience are were hosting a convention; two free been caused by untreatable genetic dis- diffi cult to replace. meals are provided per day and the eases, or scratched corneas requiring The Eye Clinic must serve this sightless are able to share conversation expensive corneal replacement, an ad- large community with very basic in- and experiences. vanced procedure the clinic does not struments, limited supplies of eye- Unfortunately, some must go perform. glasses, and limited space to manage away disappointed. Last year more Currently, the Mae Tao Eye Clin- high volumes of patients during surgi- than 800 people arrived for surgery; ic has twelve full-time eye medics, one cal events. Most of the Eye Clinic’s challenges though, revolve around access; it’s diffi cult for many patients to La La is 40 years old and has recently had eye surgery at Mae Tao Clinic (MTC), and sadly was not able to regain her vision. She is from Pago Division, Shwe Kynn Township in Bur- get to the clinic because of high trans- ma, but has been working in the Mae Sot area for four years with her husband and family. portation costs, risk of arrest, and in- ability of family or friends to leave La La is married with two children, a boy aged 6 and a girl aged 12. When they lived in work to accompany them. That makes Burma, three of her cousins and three of her uncles were murdered by the SPDC. Her husband moved to Thailand first, and she followed later with the children. They did farm work it hard for the clinic to do follow up in the Pho Pra area when they first arrived. She says her children do not go to school in care and to assess long-term success Burma as they were living in a conflict area, and in Thailand they do not go as her family has rates. It also means that some glauco- to move around to find work. She says her husband is also injured and in pain with a hernia, ma patients are forced to delay their and they cannot do strenuous work. They water plants and help planting beans on farms but she is worried that it will become increasingly difficult for them to work and earn money. At treatment until it is too late, after high the moment, her husband is still working even though he is in pain, and he earns about 2,000 eye pressures have already permanent- baht a month and one tin of rice for the family. ly damaged their vision.

La La says that she had heard about MTC from many people in her area. However, it is bit- tersweet for her as she came here to get better, and has still lost her eye. She says that in normal circumstances when her family is sick with, for example, malaria, they would not come to the clinic as it is too difficult for them to travel. She says that they will only make the journey when they are really desperate.

48 | FROM RICE COOKER TO AUTOCLAVE MTC Training Hall 1999. and a 3-month practical portion. Most of the participants of these fi rst two years had previous health care training and so this acted as a specialized upgrade training. By 1994 this was no longer suffi cient; there was a great demand for more basic health care workers, and so the program was expanded to 4-month theoretical, 4-month practical segments, covering basic health care so that individuals without any previous training could join the program. The increases still were not providing adequate training for these new participants however, so the fi rst 10- TRAINING PROGRAMS month Primary Health Care Training Health workers, doctors, or medi- have children, these services became was offered in 1995/96. This training cal students arriving on the border in essential. was conducted for fi ve consecutive 1989, no matter their specialty, were all Dr. Cynthia met with Women’s years, with trainees from other ethnic responding to the same emergency – Education for Advancement and Edu- groups and various camps along the Malaria. Residents in student camps cation (WEAVE) to discuss the need border joining in. with some type of clinic facility were for maternal and child health care train- In 2001, Burma Medical Associa- the lucky ones. For the rest, illness ing, which resulted in a 6-week pro- tion and the National Health Education meant long periods of travel, often on gram. This training, the fi rst formal Committee held a joint conference foot and by boat to seek medical care; training conducted by Dr. Cynthia, was where the decision was made to begin there were simply not enough medical conducted in 1991 inside Burma as it coordinating the training programs of- facilities to attend to the continual fl ow was identifi ed that the services were fered on the border, and to develop of new arrivals to the border. Eventu- most desperately needed in the IDP ar- standardized curriculums for these pro- ally, each camp established its own eas. The training focused on maternal grams. It was concluded that all health health care facility, but staffed with health, especially safe motherhood and organizations should be providing two only a few doctors and senior medics it family planning. After this fi rst train- levels of training: a 6-month Commu- was not enough. After about a year on ing, some of the trainees who had come nity Health Worker (CHW) Training, the border, the health workers of the from different villages along the bor- and a 2-year Health Assistant (HA) different camps began to discuss pro- der decided to return to MTC, where a Training. MTC, BMA, BPHWT and viding coordinated medical trainings, more comprehensive maternal and NHEC began collaboration to develop which led to the fi rst formal medical child health care training would be standardized training curriculums. A trainings in the student camps. conducted. The training was run in commitment was made to ongoing At this point MTC was focused 1992 and 1993 with a 3-month theory Laboratory Training, as well as to stan- on offering referral services to patients, with Dr. Cynthia providing informal First “HIV & Universal Precution” training with MSF. medical ‘discussions’ in the evenings as a means of training, with visiting doctors helping when they were there. Dr. Cynthia recalls, “We didn’t have manuals, textbooks, or a curriculum. We just started with the basics, physi- ology… malaria.” These informal trainings went on for over a year. After a couple years on the border, with acute treatment fairly well established, it was identifi ed that lacking not only at the clinic, but all along the border were maternal and child health care services. As the students started to marry and

FROM RICE COOKER TO AUTOCLAVE | 49 both inside Burma and along its many borders, the fact that such a diverse group of individuals come to MTC for the trainings also poses one of the biggest challenges – that is to say, training a group of individuals from various social, cultural and political backgrounds, with different education and skill levels. A further problem is student retention, which can be as challenging as staff retention; although it is required that participants of the training program have not applied for resettlement before beginning the training, this is not always the only problem and some students end up leaving the program due to other obligations. “3rd Maternal and Child Health” training with BMA. Training participants come from many dardize a Traditional Birth Attendant portion of travel cost for participants, ethnic groups: Arakan, Burman, Chin, (TBA) training curriculum. but does provide full support for food, Kachin, Karen, Karenni, Lahu, Mon, The growth and development of shelter, training materials including Pao, P’Loung, and Shan training programs continued in this stationery, and a small stipend for One of the Training Program fashion – an organic response to the pocket money. Although the clinic al- managers, Eh Thwa, speaks of the ben- continually changing needs of the ways fi nds a way to support the train- efi ts of these programs, “We are able to growing population on the border. The ees, there are always challenges; it is train more young people. After they MTC Training Program has grown to often diffi cult to fi nd training space, fi nish school they have the opportunity include trainings in: Prosthetics, Eye teaching materials, and knowledge- for further education. We do the train- Care, Dental, and Comprehensive Re- able, skilled trainers that are able to ing so that people can take new skills productive Health, as well as an Intern- commit the time needed. Fortunately, back to their community.” These train- ship Program for previously trained participants from large NGOs are fre- ing programs not only benefi t MTC health care workers to come for up- quently sponsored through their own and the patients that access the clinic; grade training. There are frequent organizations, relieving MTC of the fi - these are community development pro- short workshops available on topics nancial burden in these instances. grams, where the capacity of the bor- such as: Leadership Training, Gender- Although the trainings are incred- der community is supported and en- based Violence, Community Manage- ibly benefi cial to the populations living couraged. ment, Human Rights, and Environ- mental Health. MTC is viewed as an excellent training facility as it offers skilled trainers, including Burmese doctors, senior medics, and international professionals. Due to the clinic’s high patient load, it also offers extensive practical training. Although travel from inside Burma to the clinic is expensive and diffi cult, involving passage through areas of confl ict and the passing of security checkpoints both in Burma and Thailand, participants come from all over Burma to attend trainings at MTC. The Thai Ministry of Health also recognizes the strength of the training and has MTC health workers assist in the TBA trainings offered by the MoH. First Laboratory training 1994-1995, ABSDF students and Karenni students. MTC is only able to support a small 50 | FROM RICE COOKER TO AUTOCLAVE has now added education as one of its main priorities, so that when patients leave they will be better informed on health issues. For example, the staff will tell the parents what food is best for a malnourished child, or for a breastfeeding mother. Or when a child is immunized, they will tell patients al- ternate places to get immunized if they can’t follow up at MTC. Ideally, patients will take this information back with them to their communities. In 2002, School Health outreach was established mainly to provide Vi- tamin A and de-worming, and in 2004 the Integrated Management of Child- hood Illness Program brought a more holistic approach to improving clinic Medic monitors child’s services for children under fi ve. growth. Data gathered from the immunization program and curative care records goes into reports, which help CHILD OUTPATIENT with funding, and provides a picture of the population serviced to aid research. DEPARTMENT Child OPD also shares information with Thai Public Health, which pro- Although the Child OPD offi cial- with tiled fl oors, see about 100 patients vides it with vaccines. ly opened in 1998, its vaccination proper day, have electricity, a fan, a refrig- The program has expanded to gram began as early as 1995. As part erator and storage space. They have cover referrals for patients to Mae Sot of Maternal and Child Health services, their own pharmacy too, as well as Hospital and Chiang Mai Hospital for every Saturday the vaccination pro- desks and a computer. cases that the clinic cannot treat. This gram was run. For two days each has mainly been facilitated through the Twice a week, Child OPD immu- week, sessions were held for antenatal nizes over 100 children for diseas- Burma Children Medical Fund care and family planning. In 1997, the es such as Tuberculosis, Diptheria, (BCMF). This fund was set up through nutrition program was upgraded to in- pertussis, Tetanus, Measles, Polio, the clinic to fi nance the treatment of clude growth monitoring, a feeding and Hepatitis B. children externally. BCMF organizes program for the malnourished, nutri- According to May Soe and Dixie, transfers for children, and a few adults, tion education, Vitamin A supplements, in the fi rst few years after the depart- deworming, and the development of a ment opened, it serviced mainly chil- child health record. dren of migrant workers from Burma, Prior to establishing the depart- who already lived in Thailand, but as ment, adults and children had been the clinic has expanded and more peo- treated together, but as numbers of pa- ple became aware of its services, they tients and staff rose, Child OPD was have increasingly seen cross-border separated, whereupon staff become patients. Their demographic is now more specialized. When it fi rst opened, about 50% from the Mae Sot area and the department had only 5 staff mem- 50% from inside Burma. bers and saw 30-40 patients a day. It The department maintains its was housed in an open area with a roof, original focus on curative care, immu- which had only concrete fl oors and nization, growth monitoring, nutrition limited equipment. May Soe, the de- assessment and malnutrition, and is partment manager since 2002, and Di- committed to treating the common ill- xie, a medic in the department since nesses it sees, such as malaria, pneu- 2000, like to say it was a roof with no monia, diarrhea, and acute respiratory building. Now they have a building infections. However, the department Preparing medication FROM RICE COOKER TO AUTOCLAVE | 51 to Thai hospitals, where they can get A medic consultation to mother. the life saving surgery they need. These surgeries are often relatively simple and cheap, but without BCMF they would be beyond the means of most patients. May Soe and Daisy maintain that the feeding program carried out on immunization days is a very important aspect of the work they do. This program provides milk powder to families with twins, children with cleft palates, and children with no mothers or HIV positive mothers. May Soe and Daisy also say that the most common illnesses the department sees are malaria, pneumonia, diarrhea, acute respiratory infections and malnutrition. There have been many challenges for May Soe and Daisy in the daily running of their department. One of the most trying oc- whose parents usually do not know BCMF. May Soe related that the moth- currences is when parents leave their what is wrong. They can’t get treat- er was very happy and relieved at not children at the clinic and never return, ment or even diagnosis in Burma, and being forced to give up her child. which has happened three times so far. this is highly stressful for them. May May Soe and Daisy have many Also, like the clinic as a whole, the de- Soe remembers one such case where aspirations for the future of their department is continually growing, and the mother had become so distraught partment. They hope one day to ex- there is still a great need for more prior to coming to the clinic that she pand into two departments, Curative space. had contemplated giving up her child. Care and the Immunization and Feed- Nevertheless, there have been The staff at Child OPD was able to ing Program. They would also like to many uplifting experiences within the properly diagnose the child as having a have more space to build a play area department. For instance, staff often congenital heart condition, which was for the children who come to the clin- sees young patients with heart disease, subsequently treated with funding from ic. CLINIC LIBRARY The Mae Tao Clinic library grew dramatically since its original incarna- out of the idea that providing books to tion as a box of books at the clinic that When the library opened in 2001 it was staff and patients would relieve stress staff shared and swapped with each only seeing up to 30 people a day. Now it provides services to over 100 people and tension, while at the same time other before 1994. The library now has per day. providing information and education. approximately 100 visitors daily and The aim of the library is to provide re- over 5,000 books. The library offi cial- are coming to borrow books. He says lief from boredom, as well as serving ly opened in 2001 when it was decided that patients and staff now often re- an educational tool. This is refl ected in to turn the expanding collection of quest books from him, which shows the array of books the library now of- books into a proper library. When Hla him that people are engaging with lit- fers to its patrons. These range from Thein took over the running of the li- erature and the library’s services. Hla medical texts and literature on human brary in 2003, he was the only staff Thein would like to see the library de- rights and politics to love stories and member; now there are seven staff velop in the future. He hopes that one novels. members on the team running the li- day he can get the medical texts trans- Dr. Shee Sho was very active in brary from 8am-9pm daily. lated into Burmese from English, since establishing and organizing the library Despite the expected challenges currently it is only possible to get them services and KWO members helped of obtaining more books and retrieving in English. In addition, he would like with the numbering and registering them from borrowers, Hla Thein is to see the library have an exclusive system. Hla Thein, the library manag- proud of the library. He is most proud space that is not interrupted by meet- er, says that the library has changed of the fact that more and more people ings.

52 | FROM RICE COOKER TO AUTOCLAVE challenges for the medics is to manage the psychosocial aspects. While the death rate is very high, the community spirit of the patients is unbreakable. The HIV/AIDS patients stay in the clinic for a long time, become a close- knit community, and take care of each other. Unfortunately, there is no space in the ward for relaxation or recreation for long-term patients, and many don’t have suffi cient clothing, blankets or basic necessities. One byproduct is that the visual impact for visitors can be a shock. Desperately poor patients arrive with few basic necessities and after long travel. The patients often leave with blankets, meaning that the clinic is constantly in short supply, some patients are accompanied by an entire family who may sleep under their bed, and they can be very dirty MEDICAL & CHILD due to travelling and sleeping on the fl oor. While they may receive good INPATIENT DEPARTMENT care and treatment, there may be visual shock at the patient’s physical appear- In 1998, about 80% of admissions displaced already, they fear getting ance in the crowded and disorganized were related to malaria. Over time, the split up by circumstances if they don’t ward. Dr. Cynthia stresses the impor- range of illnesses treated has become travel together. For example, in the tance of looking past the initial appear- broader – but the constant over time case of arrest or deportation, they could ance, avoiding judgment, and looking has been that patients arrive at the clin- have great diffi culty fi nding one an- more closely at the most important ele- ic with illnesses in advanced states. other again. The family may not have ments – quality of care and strength of Since many patients arrive with termi- the resources to travel back and forth to the community. nal illness, the IPD functions part of the clinic every day, or have diffi culty Under the misnomer of a “clinic”, the time like a hospice. Working con- travelling freely due to security. Some- Mae Tao Clinic also functions as a hos- stantly with terminal patients has a times, the family members will search pital facility, with several inpatient de- strong impact on the younger health for some work in Mae Sot while at- partments (IPD). Until 1999 there was workers. If the patients could have a tending to a sick family member. only one inpatient department, treating higher level of health knowledge, act One might be tempted to declare medical, trauma, reproductive health, more on prevention, and obtain treat- victory when a patient’s condition has and child inpatients all in the same ment earlier, many of the conditions, improved and is able to go back home. space. In 1999, the continually grow- such as malnutrition for example, However, for many patients, this mere- ing patient population led to the expan- would be preventable or treatable. The ly heralds the beginning of the next set sion of the clinic and separation of de- IPD also faces family issues – a patient of challenges. They may not have partments, eventually resulting in the may be dropped at the clinic by friends money to get back home, face security Medical, Children’s, Reproductive or family, however, these people fre- and travel challenges, and their old job Health, and Trauma/Surgery IPDs that quently cannot afford to miss work in may no longer be waiting for them exist today. order to be their attendant. The respon- even if they do complete the journey Today the Medical Inpatient Depart- sibility falls upon the medics to support without incident. ment has 50 beds, with overflow space patients who face death without friends In order to carry out their duties for another 10-20 patients, and the Chil- or family. successfully, the IPD medics must pos- dren’s Inpatient Department has space In other cases, the whole family sess medical ability, as well as the abil- for 20 patients, with overflow space travels to the clinic together. They may ity to counsel patients, support them, also available. live far away and are unfamiliar with and refer them to other clinic social Established in 1999, the Medical Mae Sot. If the family is migrant or services. One of the most diffi cult IPD was a combined service for both FROM RICE COOKER TO AUTOCLAVE | 53 adults and children. The most common cases seen continue to be malaria, acute respiratory infection, and diarrhea, with a continuing increase in the number of chronic cases being seen at the clinic, including cancer, sclerosis, hypertension, nephritic syndrome, and heart disease. Among children, malnutrition is also a common case, and this was one of the leading reasons for the development of a separate Children’s IPD in 2005; children with weakened immune systems needed to be separated from patients with contagious illnesses. Beyond the regular patient caseload, staff of MTC must be prepared for the unexpected, such as the cholera outbreak in 2007, or other effects of extreme weather seen in tropical cli- I see sick patients, and I can’t do any- resettle in a third country, “We are hu- mates. The rainy season from May to thing for them, I feel very sad. And man beings. We want to improve our September for example, always brings when the patients die…we see a lot of lives. If we are just living, with noth- an increase in the number of patients death.” ing to hope for…people don’t want to arriving with malaria. Also, the further The Medical IPDs are also live like this.” word spreads of the services of MTC, plagued with the challenge of staff re- There is hope that the future will the more chronic cases are presented at tention . Saw Muni summarizes the see the training of more long-term the clinic. Even in a well-equipped, plight well, “If we look for our strong staff, especially as there are more plans modern hospital setting, these cases points…we have trained a lot of med- for expansions in Medical IPD. As an would be an extreme challenge. ics. If we look for the weak points…we example of possible future develop- have trained a lot of medics that have ment, the department still requires bet- IPD is open 24 hours a day, 7 days a week with three shifts per day and 80 staff. left.” With the introduction of a reset- ter isolation of patients with communi- tlement program in 2004, the clinic has cable diseases, especially now that For severe cases that cannot be suffered extensive loss of staff, but there is no longer an external Tubercu- treated at MTC, the referral program to Saw Muni expresses the understanding losis program to send patients to. Mae Sot Hospital (MSH) becomes a and acceptance for those that choose to There is also the hope for greater coordination and partnership with other possibility. Department Manager, Saw A child get severe pneumonia. Muni, and the staff of the Medical IPDs health organizations, Mae Sot Hospi- are charged with the unenviable task of tal, and the Thai community. Commu- deciding who will be referred for treat- nicable illnesses such as TB quickly ment and who will not be. There are become devastating public health is- procedures and protocol to follow, but sues that don’t recognize borders. The this does not make it easier. Staff must increase in cross-border patients re- fi rst consider the potential survival rate quires greater collaboration in the com- of the patient, and then the cost of treat- munity to battle health issues. ment, referring only the patients that The IPD cannot alone solve the require a one-time visit to the hospital, problem of cross-border tuberculosis, and not ongoing hospital visits. Of malnutrition, lack of health care inside course these decisions are made in de- Burma, or the extreme social and eco- veloped countries, but not to this ex- nomic challenges of the patients. The tent, and not on a daily basis. Frustra- IPD aspires to treat the patients with tion and sadness is evident when the best care possible with its resourc- talking with Saw Muni. “I am sad be- es, utilizing strong collaboration with cause we cannot treat all of the patients, other clinic departments as well as oth- we don’t have enough facilities or er organizations to address the broader enough money to refer the patients. If issues that result in its high caseloads.

54 | FROM RICE COOKER TO AUTOCLAVE FINANCE & ADMINISTRATION Prior to 1992, medical supplies Finance team at work. were donated, and the clinic survived using various donations-in-kind. For- tunately, there were regular monthly and quarterly donations from organizations such as Médecins Sans Frontières of rice and medicine. If patients were referred for treatment at Mae Sot Hos- pital, supportive church groups would pay the hospital directly. From 1993 onwards, funding for running costs was donated by organizations such as the Burmese Relief Center. This provided funding for basic necessities of the staff, phone bills, and other administrative costs. Fortunately, other groups began to provide funding as well for running costs. In parallel, there was a need to develop the medical administration. For example, there was initially only one medical record and log book for- caused MTC to begin catering to spe- clinical space grew and began to sprawl mat which was used by all departments. cifi c donor requirements. More staff across the grounds into new buildings, Separate antenatal care, family plan- was required to monitor supply and more coordination was needed. After ning and delivery records format were medicine expenses and to match those 1999, departments were established as developed in 1994. In 1995 the fi rst to donor requirements, and the order- decentralized entities with some cen- annual report was published, but until ing system needed to be decentralized. tral coordination. Each department 1999 there wasn’t a dedicated staff of This development allowed each de- now has a program manager who man- professional administrative staff. Until partment’s program manager to inde- ages logistics, staff issues, budget and 1999 a small offi ce team managed to pendently manage logistics, staffi ng supplies. There is also a clinical super- reply to correspondence or requests to and expenses. Furthermore, although visor, and shift leaders for the inpatient the clinic. However, 1999 marked the each department was able to send re- departments. In each department one beginning of building out the adminis- quests to the central pharmacy, they person manages the pharmacy - if there trative and fi nance backbone of the also kept a separate pharmacy storage is enough staff, this is a separate per- clinic. The fi rst clinic administrator area, and in this way individual depart- son, but many times the program man- and accountant were appointed, and ments operated like tiny hospitals. ager does this in addition to their other the fi rst audit conducted. For many Throughout the early years, MSF duties. years MTC didn’t keep its own records had been providing quarterly medicine When a new department is creat- – all receipts and records were sent donations-in-kind, but this eventually ed, a new logbook and report format is back to the donors and MTC didn’t proved insuffi cient for the clinic’s created. At the outset, however, there have its own fi nance system. There- caseload. From 1999 onwards, donors was no consistency or complete data fore, fi nancial audits were done within began providing grants that were used across the reporting formats which the donor organizations. In 1999 the for quarterly medicine orders through a made it diffi cult to consolidate infor- clinic started to keep its own receipts local supplier. Terre Des Hommes mation into an annual report. In 2002 a and fi nancial records which could be (TDH), for example, supported specifi c data coordinator was appointed to audited. areas in the clinic. Due to growing do- oversee logbooks, data entry, and data The other change from 1999 was nor requirements, the clinic needed to quality. This coordinator trained clini- the method of ordering supplies and change the ordering system. More cal staff to do data entry, but their clin- medicine. From 1989 – 1999 there people were needed to monitor medi- ical skill set was not suitable, and this was a central ordering system, but in- cine expenses and to ensure these resulted in staff turnover. When the creased grants with specifi c purposes matched donor requirements. As the data department was fi nally established

FROM RICE COOKER TO AUTOCLAVE | 55 and data entry staff was hired, the data ductive Health areas. The support of processes continues to this day. To quality improved. (For further discus- the WCRWC for two years enabled re- support this initiative full time fi nance sion see the Health Information Sys- view and revision of the logbook for- manager was appointed in 2005. While tems chapter) From that time on, data mat, establishment of a data collection the title might mislead one to thinking quality has continually improved and system, revised medical reports, and a the role was mainly related to “bean- obtaining consolidated fi gures across facility checklist. An important facet counting” or tallying the fi nancial fi g- the clinic and reporting to donors has of current clinic operations also began ures, the role encompasses fund rais- become easier and more accurate. – the exit interview. This has enabled ing, auditing, reporting, and process In addition to the establishment MTC to better understand patient ill- improvements to ensure clear report- of the data department, a concomitant nesses, situations, and satisfaction. ing. In 2007, a procurement team was driving factor behind administrative The program also introduced quality established, which set a policy as well developments in the clinic was the in- assurance measures such as updated as managed the procurement and logis- creasing role of MTC as a refugee ad- clinical protocols and medical case au- tics of the clinic. Recognizing the im- vocate and social service provider and dits. This project was the beginning of portance of dialogue with donors, the coordinator. From 2000 onwards, the MTC’s monitoring and managing of fi rst meeting inviting all donors to dis- increasing population of migrants and health care delivery quality. cuss clinic issues was held in 2007. health problems, gave rise to more Once MTC had set up the ac- These annual meetings cover issues NGOs working with migrants. MTC counting system, changes and require- such as funding needs, standardization

Noddle factory location at current offi ce. decided to appoint its fi rst migrant ments began to increase exponentially. and schedule issues. health coordinator. Until then, the Some donors, for example, require Prior to the appointment of the clinic had restricted its activities to separate fi nancial reporting, in which clinic administrator , public relations providing services, referring patients case a specifi c accountant needs to be duties were shared by clinic staff. The to other NGO services, and recording appointed to that project. Even though frequency of visits from donors, uni- case counts. However, there was no some projects have these standalone versities, media and civil society began system to monitor the quality of ser- fi nances, the overall clinic fi nances to increase with the clinic’s notoriety vices provided. The Migrant Health must always be integrated for reporting from 2000. Finally in 2008, an interna- Coordinator set out to monitor care in purposes. Initially, an international tional volunteer was appointed to lead the migrant community, but this was volunteer was appointed but each year Public Relations. This led to clear just the beginning of a broader advo- a new person would take the role. The guidelines for media tours, referring cacy role the clinic would begin to play other challenges were that some donors visitors to departments, and visitor both locally and internationally. required quarterly reports, while others protocols. This role has now been tran- On the clinical side, in 2001 a required half-year reports. The clinic sitioned to local staff. These days, the program in collaboration with the needed to be able to strengthen the sys- local staff continues to increase its Women’s Commission for Refugee tem to support timely reports contain- ranks of young, multi-lingual, educated Women and Children (WCRWC) ing both narrative and fi nancial infor- and polished members who are capable brought improvements to the Repro- mation. The strengthening of these of taking the lead in this area.

56 | FROM RICE COOKER TO AUTOCLAVE STABILITY AND SECURITY FOR MAE TAO CLINIC With 20 years of service under its belt, the Mae Tao Clinic offers its community a sense of stability and security. In a region which continues to endure ongoing confl ict and volatility, it is reassuring to know that there is a community-based organization such as the Mae Tao Clinic which has been able to offer hope for the future for over two decades. Yet, there have been times in the last 20 years when the services and the existence of the Clinic were questioned, possibly even threatened. Dr. Cynthia explains, “In the late 1990’s, the attacks came across the border into Mae Sot. At that time, all the clinic staff slept together in one building. There was a woman brought to MTC for care since she was terribly traumatized who would wake up in the middle of the night screaming. One night when attacks were not uncommon, she woke up screaming. By the time I saw what was happening, wondering if there was an attack, the whole staff had already fl ed. I noticed they each grabbed a bag and ran out the door. It was only at that moment I realized that everyone slept with their belong- ings packed, ready to go, ready to fl ee at any moment.” As the Clinic has continued to grow, its visibility has increased - certainly in the eyes of international supporters, and even among the host community where the Clinic maintains as low a profi le as possible to avoid unnecessary tensions with the local community. Being without offi cial recognition as a Thai-registered organization, the Clinic has operated dis- creetly, giving importance to the kind understanding of the host community leaders and taking care to engage in full cooperation with local authorities. Even then, there have been times when MTC faced challenges, for example, due to changes in the interpretation of the work permit rules. Each time the Clinic has come under pressure, Thai senators empa- thetic to the situation along the Thai-Burma border, and other prominent international supporters, have come to the rescue and have helped to forge deeper ties between the Clinic and concerned parties so that discussions could continue. Situated in the complex reality of competing politics and economics, the Mae Tao Clinic has had to work hard at balancing the needs of its people – both patients and staff, against the turmoil that sur- rounds it. Each day may bring a new crisis to its door, each year a larger clientele to treat and heal. Even after 20 years, the sense of stability and security that the Clinic will be there for those who need it is continually challenged by the changing landscape of the local context. Long term funding security is a constant challenge. The events of 2004, for instance, resulted in one of the more severe crises in the clinic’s history, when a large infl ux of cross border patients came at a time when there were no new increases in funding. There are still some fundamental concerns that keep the Clinic on its toes besides funding issues – such as not being able to own the land that the Clinic stands on, not being able to secure long-term documentation and residency in Thailand for its staff, and not being able to own assets in its name. Lamentably, these issues sometimes negatively affect the operations of the Clinic, and thus the Clin- ic strives to ensure greater security and stability as opportunities arise. In the end, it is clear that recognition and support at all levels - locally, na- tionally, and globally - are essential elements in ensuring that the Clinic can continue to serve its community and provide hope for the day when a democratic Burma can emerge. FROM RICE COOKER TO AUTOCLAVE | 57 PARTNERSHIPS: 1995 - 1999

BACK PACK HEALTH WORKER TEAM

• In 2007, Back Pack Health equipped to treat the disease; instead, two to fi ve members, and overall serve Worker Team (BPHWT) distributed they educate patients about TB and re- about 160,000 people displaced by de-worming medicine, vitamin-A tab- fer them to other service providers for civil war in Burma. Back Pack Teams, lets, latrines, soap and health education treatment. laden with 100 kilograms of supplies, to 21,962 students and 1,009 teachers • In the past 11 years, seven back often walk more than 1,000 kilometres in 353 schools. pack health workers and one traditional to deliver health care in ethnic confl ict In the IDP areas, BPHWT ad- birth attendant have been killed while areas. dresses three areas: medical, public delivering health care. One health The focus of the Back Pack mod- health promotion prevention, maternal worker, imprisoned in 2005, and three el has been to train local people in pri- and child health. village health volunteers remain in mary health care and some specialties • The medical program treats ma- prison. Two health workers captured in so they can serve their own communi- laria, diarrhea, acute respiratory infec- 2007 were released after payment of ties. Typically, Back Pack teams visit tions (ARI), anemia, worm infestation “fi nes.” The junta regularly steals med- Mae Sot every six months where they and war injuries. Malaria is the most ical supplies. re-supply and attend training. Each common disease, followed by ARI, The Back Pack Health Worker team then shoulders 100 kilograms of worm infestation, anemia, diarrhea and Team began in 1998 with 32 teams in provisions and heads back over the dysentery. the Karenni, Karen and Mon areas. border, traveling mostly on foot through • Tuberculosis is a growing major Today, there are 80 team which have mountainous jungle terrain. Their des- health problem among internally dis- expanded their territory, also reaching tinations are the rural and ethnic armed placed people. In 2007, back pack into Arakan, Chin and Shan areas. In confl ict areas where medical care is teams identifi ed 430 suspected cases of the Shan areas, there are Lahu, Pao and scarce or non-existent. Walking as far TB. Back pack health workers are not Shan teams. These teams each have as 1,000 kilometres in a single trip, the teams provide a range of medical care along with community health education and prevention, and maternal and child healthcare services. In bamboo classrooms and simple encampments, health workers teach villagers sanitation and hygiene, how to breastfeed, nutrition, and how to prevent landmine injuries, malaria, diarrhea, avian infl u- enza and HIV/AIDS. BPHWT’s maternal/child health program includes family planning and breastfeeding education. In a place where one out of 12 women dies in pregnancy or childbirth, BPHWT has A Backpack medic gives Vitamin-A to IDP children. trained 720 traditional birth attendants

58 | FROM RICE COOKER TO AUTOCLAVE in safe birth techniques and provided months had double the chance of dy- lagers to prevent disease? “Malaria is them with life-saving birth kits and ing, and triple the chance of becoming a disease we can prevent with bed nets. supplies. BPHWT’s mission is to malnourished. In the 12 months after Are we going to provide bed nets? Or equip people with the skills and knowl- being forcibly relocated, the study are we going to treat the people who edge necessary to manage and address found a fi ve-fold increase in the risk of are sick right now? Prevention is bet- their own health problems, while work- landmine injury for both children and ter, but at the same time, health working towards long-term sustainable de- adults.19 Destruction of families’ food ers have a moral obligation to help the velopment. “Human rights violations supplies and crops not only increases sick,” says BPHWT executive director have commonly been reported by rights malnutrition, but also increases the Mahn Mahn. organizations, but the association be- chance of landmine injury and malaria Despite this dilemma, back pack tween violations and health indicators as people are forced to forage in the health workers treat as many patients has not been quantifi ed” prior BPH- jungle and sleep in beds lacking mos- as they can and distribute whatever bed WT’s work in this area. A study was quito nets. This is a particularly impor- nets they have with the realization that undertaken in collaboration with Johns tant statistic providing that at any given nets may get left behind when people Hopkins University in 200418 Which time, 12 percent of the displaced popu- fl ee a burning village. “Because so used epidemiologic methods to dem- lation is infected with Plasmodium fal- many people are displaced, the diseas- onstrate links between human rights ciparum, the most deadly form of ma- es will be coming again and again,” abuses and adverse health outcomes. laria. Mahn Mahn says. “I always say: Stop The report found that children who had With limited resources and such the human rights violations among been forcibly relocated in the last 12 high rates of disease, it’s always a chal- these communities! Health care is an lenge to prioritize: should efforts be issue that could bring people together 18 “Population-based survey methods to quan- focused on treating the ill, or should who would otherwise be fi ghting each tify associations between human rights violations and health outcomes among internally dis- resources be directed at teaching vil- other,” Mahn Mahn says. “People need placed persons in eastern burma” Mullany et al, to meet, understand and trust each oth- Journal of Epidemiology and Community Health, 19 Chronic Emergency: Health and Human er.” 2007; 61:908-914. Rights in Eastern Burma, 2007.

KAREN WOMEN’S ORGANISATION (KWO) After the December 1996 attacks up community projects. KWO has set the years,KWO has worked along side in Dooplaya and February 1997 attacks up libraries, nursery schools and in- MTC to further advocacy and commu- in Hway Kaloke, KWO stepped in to come generation projects in the refugee nity development. These days, MTC support the affected women and chil- and IDP camps. Starting in 1999 KWO and KWO work together on programs dren. MTC has been working in part- worked together with MTC to write for Traditional Birth Attendants, Ma- nership with KWO ever since; initially funding proposals and to build of the ternal Health, adolescent reproductive on emergency relief and later on to set capacity of both organizations. Over health, and Child Protection.

KARENNI NATIONALITIES HEALTH WORKER ORGANIZATION The Karenni Nationalities Health medics travelling to the clinic to assist thetic training at MTC they are now Worker Organization has set up clinics the set-up. Staff exchanges were done able to build their own prosthetics since in the Karenni state, with medics at- to facilitate knowledge transfer across 2008. tending training at MTC and MTC the organizations. After attending pros- SHAN HEALTH COMMITTEE

After the massive forced reloca- is recognized by the Thai Ministry of ma Medical Association to the same tion of over 300,000 Shan people in Health as a model clinic for migrant end. SHC also worked in partnership 1998, the Shan Health Committee workers in Thailand. with MTC and set up a prosthetics (SHC) established Tin Tad Clinic on In staff exchanges similar to those workshop, and conducted their own the Thai side of the border, which still done by the Karenni Nationalities community health worker and labora- operates today in Fang. MTC helped to Health Worker Organization, SHC sent tory training. SHC is an example of establish this clinic, which has now their medics to MTC for training and partnerships creating an empowered been ofﬁ cially recognized as a Thai did staff exchanges and knowledge community. health post. Today, this clinic in Fang transfer. They also work with the Bur-

FROM RICE COOKER TO AUTOCLAVE | 59 60 | FROM RICE COOKER TO AUTOCLAVE 2000 – 2004: BUILDING CAPACITY

A child patient at Child IPD (photo: James mackay, www.enigmaimages.net)

FROM RICE COOKER TO AUTOCLAVE | 61 HEALER OF BROKEN SOULS

clinic in Karen state enabled her to wit- ness fi rsthand the poverty and disease endemic under Burmese military rule. She was among the euphoric millions who joined nationwide antigovernment protests in 1988—and, a few months later, one of thousands who fl ed over the border into Thailand to escape a savage crackdown. Traveling at night to evade army hit squads, Maung and 14 colleagues trekked through the jungle for seven days, stopping only to treat the sick and injured they came across with the few supplies they had carried. Although she has now lived in exile in Thailand for 15 years, Maung has no offi cial papers and is effectively Dr. Cynthia Maung, the 43-year- movement herself, Aung San Suu Kyi. stateless. The clinic is her country now. old founder of Mae Tao clinic in the If you were a Burmese general, you’d Private and unassuming, she lives in a Thai border town of Mae Sot, is an ab- hate Maung, too. modest house at its gates, along with sconder, an insurgent and an opium- “When I fi rst arrived in Thailand her husband and three children, the last smuggling terrorist. Any attempt to I thought I’d be here for only three a baby girl adopted after being aban- deny this is as futile as covering the months or so,” recalls Maung, a hand- doned by her mother at the clinic. rotting carcass of an elephant with a some, soft-spoken woman who ema- Maung places enormous faith in goat hide. nates serenity even in less-than-serene her medical staff despite their lack of That, at any rate, is the opinion of circumstances—in this case, with doz- formal training, and they return this Burma’s ruling military junta, as pub- ens of infants howling from immuniza- faith with fi erce loyalty. “For Dr. Cyn- lished on its reliably absurd and mali- tion jabs in her clinic’s child-health thia, nothing is impossible,” says Tara cious website. The generals have every center. “Then I thought I would go Sullivan, an American reproductive- reason to despise “Dr. Cynthia,” as her back in three years. Then fi ve years. I health expert who has worked along- patients call her. In 1989, equipped always thought the political situation side her for two years. “She has a great with medicines scrounged from foreign in Burma would improve.” Instead, it sense of humor and a great sense of relief workers and instruments she had got worse, creating an ever-growing purpose.” Clinic administrator Rae sterilized in a rice cooker, she trans- caseload for Maung and her staff. Svarnas says, “She’s an incredibly hard formed a dilapidated barn in Mae Sot While the clinic hasn’t lost its make- worker. She never asks anyone to do into a clinic to provide free treatment shift feel—the beds in its 49-bed inpa- something she wouldn’t. And in two for the sick and wounded fl eeing Bur- tient ward are wooden trestles covered years I’ve never seen her angry. Nev- ma’s oppressive regime. Today, thanks with fl oor linoleum—it has expanded er.” With her medical qualifi cations to her preternatural drive and opti- to include a trauma department, blood and experience, Maung could easily mism, up to 200 patients—mostly mi- and eye labs, and a prosthetics depart- claim asylum in a third country. Has grant workers and refugees from across ment for land-mine victims. The clinic she ever been tempted? “Work abroad?” the border—pass through her clinic ev- also serves as a training center for the she asks, as if I’ve just suggested we ery day. Its fi ve doctors and 120 other famous “backpack medics”—teams of tango through the inpatient ward. “I’ve medical staff treat everything from di- doctors who make perilous treks deep never thought about it. The West has arrhea to gunshot wounds, all for a pa- into the Burmese jungle to treat people enough doctors.” Which is a relief to tient registration fee of just 25¢. Maung with no access to medicine. The physi- hear, because as tens of thousands of has won a slew of international prizes, cians occasionally have to resort to her patients would attest, impoverished most recently a Ramon Magsaysay jungle amputations to save lives. and benighted Burma needs all the Award for community leadership, and Maung understands what it’s like doctors it can get—and all the heroes, remains among her own people the to be a refugee—she’s one, too. Born too. likeliest candidate for sainthood after into a Karen family in Rangoon, her by: Andrew Marshall, Time Magazine, 2003 the leader of Burma’s pro-democracy work as a young doctor at a tiny rural

62 | FROM RICE COOKER TO AUTOCLAVE ONE REFUGEE CAN CHANGE THE WORLD 80,000 patient visits to its facilities. girls attend school and offers job skills In addition to the Clinic’s com- training. The increasing numbers of prehensive inpatient and outpatient abandoned infants at the Mae Tao Clin- services, Dr. Cynthia and the Clinic’s ic and the district hospital refl ect the volunteer staff support education and critical problem of unwanted pregnan- social services, including two schools cy and the need for family planning for orphaned children. The Clinic also among internally displaced women in hosts regular extensive training pro- Myanmar and others living in refugee- grammes for health workers, who then like circumstances. work in migrant communities along Dr. Cynthia has lived in exile for the border, among the internally dis- 15 years and effectively stateless, at placed in Myanmar or with interna- constant risk of being deported along tional organizations in one of teh refu- with the 150 volunteer staff who work gee camps in Thailand. with her. She lives in a house at the Dr. Cynthia has trained some 70 Clinic’s gates, along with her husband backpack health worker teams, each and three children, including a baby comprosed of two medical assistant girl adopted after she was abandoned and a traditional birth attendant. The by her mother. teams provide health services to inter- Dr. Cynthia’s humane and fear- Dr. Cynthia Maung has under- nally displaced people at great peril to less work truly embodies the spirit of gone a dramatic transformation. Once their own lives, resking possible land- Security Council resolution 1325. Un- a rural Burmese doctor, she became a mine injurirs and military attacks, in der her direction, the Clinic has re- victim of war, then a refugee and exile, ara of Myanmar where government ceived numerous international acco- and is now a world-renowned human services are not available and interna- lades - including the Jonathan Mann rights leader helping thousands of des- tional non-governmental organizations Heatlh and Human Rights Award, the perate people from her country. are not allowed to go. John Humphries Award and the presti- Known universally as Dr. Cyn- In 200, Dr. Cynthia helped to gious Magsaysay Award - for its com- thia, she was working as a doctor in a found Social Action for Women, which passionate and courageous work in ad- rural clinic in Myanmar in 1988 when eatablished a ten-bed temporary safe dressing the health and human rights of political turmoil and confl ict forced her house for abandoned infants and young ethnic Burmese people in Thailand and to fl ee to neighbouring Thailand. There girls who have suffered gender-based the internally displaced in Myanmar. she established the Mae Tao Clinic in violence or who are seeking to escape (Faces, Women as Partners in Peace and Mae Sot, Tak Province. commercial sex work or forced prosti- Security 2004, Offi ce of the Special Adviser on The Clinic has grown from a Gender Issue and Advancement of Women (OSA- tution. The organization provides in- small, makeshift operation in 1989, GI), Departmetn of Economic and Social Affairs, formation on HIV/AIDS and other re- United Nations Department of Public Informa- with a few volunteer staff assisting productive health issues, helps young tion.) aproximately 1,700 patients, to become one of the leading organizations on the Thai-Myanmar border. Today, more than 250 staff and volunteers provide critically needed and culturally appropriate health care to thousands of ethnic Burmese and migrant workers living in desperately poor circumstances in Thailand, as well as internally displaced persons in Myanmar who undertake the dangerous, illegal trip across the border to Thailand to obtain health care at the Clinic. The Clinic also provides health services for thousands of internally displaced persons at two satellite clinics in Myanmar. In 2003, the Clinic porvided for over

FROM RICE COOKER TO AUTOCLAVE | 63 are supposed to provide for and protect. “I have seen that most [landmine survivor] patients have little confi dence in themselves after they get their prosthetic, including me,” he says. “They got injured not only physically but mentally…some don’t even listen when they are told how to take care of themselves after their amputation. I understand how they feel, because I was also feeling the same way a long time ago.” Dr. Cynthia helped Saw Maw Kel set up the prosthetics shop at the Mae Tao Clinic after a workshop he started with Dr. Cynthia’s support at the Mae La Poh Htah IDP camp was burned to the ground. Less than a year later, Saw Maw Kel and his staff of one, Moe Khar, had treated 30 patients from Bur- ma. Year by year, the shop grew from a simple room with no power tools into a modern prosthetics production facility. Amputee coaches boxing (photo: Tom Reese @ Seattle Times) Lamination was the primary method of making artifi cial limbs. In 2005, with the support of Clear Path International, PROSTHETICS DEPARTMENT the monolimb was introduced. Light and partly vacuum-formed, the mono- • Burma is second only to Afghanistan cial leg to heal. “In our culture, the limb promises faster production and in the number of new landmine victims man is the leader of the family and easier delivery to IDP areas, but re- each year. more responsible for taking care of the quires complex and precise techniques. • 95% of the program’s clients come family,” says Saw Maw Kel. Many Today the shop’s crew of 6 can make from Burma landmine survivors suffer humiliation more than 200 limbs a year, using both From the outside, the prosthetics and shame when their injury makes lamination and monolimb methods. department looks like another plain, them dependent on the loved ones they Throughout the program’s histo- heavy concrete cinderblock building - one among the many that form Mae Tao Clinic’s maze of structures. Inside the bland façade however, is a workshop that gives hope to landmine victims – hope in the form of prosthetic limbs, food and shelter, social support, and the knowledge and expertise of staff that know fi rsthand the diffi cult journey that landmine survivors have made. Saw Maw Kel is a sturdy Karen gentleman who founded the Mae Tao Clinic’s prosthetics program at the end of 2000 and has been a driving force in its development ever since. A landmine survivor himself, Maw Kel experienced the psychological wounds that accompany the physical injury – a Prosthetic workshop at MTC. wound that takes more than an artifi - 64 | FROM RICE COOKER TO AUTOCLAVE A landmine ry, most of the prosthetics trainees have long journey of rehabilitation. At the been landmine survivors themselves. Mae Tao Clinic, in addition to pros- Ninety-fi ve percent of the Mae Tao thetic limbs, patients receive food and Clinic’s Prosthetics Program’s clients housing, and social support services. come from inside Burma. Moe Khar, They also get gait training – in essence, now the prosthetics department man- relearning how to walk. The clinic be- ager, says that 17 out of 20 patients that gan offering mental health counselling come each month have lost their limbs specifi cally for prosthetic patients in to landmines. Accidents, disease, and 1998. Today prosthetics patients can congenital defects make up the remain- get help at the clinic’s counselling cen- ing 15%. The vast majority need lower ter that opened in 2006. limbs. When a client needs an upper In addition to the successes, the limb, a sponsor is sought to purchase program faces hurdles that are beyond Artifi cial leg and deliver the materials for an artifi - the clinic’s control. The supply of arti- cial arm. fi cial feet, ordered from Cambodia by nancial future seems secure, as an Ital- The Mae Tao Clinic refers newly- Handicap International, often cannot ian community organization has guar- injured landmine and gunshot wound keep up with the demand. It is diffi cult anteed the clinic’s prosthetics program victims to Mae Sot Hospital for stabili- to fi nd local people willing and able to long-term support. Eventually the zation and initial surgery. In 2004, the give physical therapy and limb mas- clinic hopes to produce artifi cial feet ICRC began supporting the referral sage to patients, and lastly, with such a in-house to reduce the reliance on sup- program by paying for patients’ initial small staff, the shop acutely feels the ply from the outside. medical expenses and conducting as- loss of experience and knowledge The legacy of the Mae Tao Clin- sessment interviews. After their ampu- when a technician resettles overseas. ic’s program will not only be the land- tations, landmine survivors begin a Fortunately however, the program’s fi - mine survivors it has served, but the many technicians that have graduated Saw Maw Keh from the program’s prosthetics workshop training. Some from ethnic minorities have returned to their communities inside Burma to apply what they learned in Mae Sot, bringing hope to landmine survivors who are unable to make the arduous trek to the border. For Saw Maw Kel, the satisfaction comes from seeing amputees make the mental journey from victim to survivor. Though the prosthetic limbs are an imperfect replacement for what was physically lost, they are pivotal to recovering a wholeness of being. “I am happy and proud,” Maw Kel says, “to see those who have lost parts of their body like me, regain confi dence and struggle for life without giving up.”

FROM RICE COOKER TO AUTOCLAVE | 65 tral database that the clinic could use for planning, budgeting, and reporting to donors. Thanks to the generosity of foreign donors, getting computer hard- ware and software has not been the main challenge. Rather, the biggest obstacles are developing staff with database skills and knowledge, keeping the system going as experienced staff leave and new staff come on board, and educating clinical staff on the importance and value of information. Some of the best examples of the system at work are in communicable disease public health. As tuberculosis emerged in recent years on the Thai- Burma border, the clinic used its health information system to determine the HIS staffs working time. proportion of cases coming from Bur- ma. In 2003-2004, Tak Public Health conducted a pilot project with MTC, HEALTH INFORMATION helping the clinic improve its database’s ability to monitor 19 infectious SYSTEMS diseases of public health importance. Getting accurate information on pharmacists can still dispense the prop- During a cholera outbreak on the bor- time is the mission of the health infor- er medications, and babies are still de- der in 2007, the information in the mation systems department (HISD). livered. Without these numbers how- clinic’s database was used to conduct How many cases of a certain disease ever, planning, a crucial element in the surveillance for the deadly diarrheal has the clinic seen? What is the per- development of the clinic and the ser- disease. centage of female patients? Where do vices it provides, is impossible. How In 1995, MTC had only two computers – the clinic’s patients come from? These can you know how many anti-malarial one for Administration, another for a DOS are the types of questions that the HISD pills to order for July unless you know learn-to-type program. seeks to answer, but before the devel- the number of patients with malaria Today HIS has 24 desktop computers and 11 laptops spread across 12 departments. opment of an electronic health infor- you saw this June or last July? How mation system, answering such basic can you know how much money to The next big step planned for the questions was laborious. It meant fl ip- budget for medications and supplies clinic’s health information system is to ping through pages and pages of clinic for the Trauma and Surgery Depart- introduce a fully centralized database. logbooks to get each patient’s name ment unless you know the numbers of Today, to update the clinic’s main data- and diagnosis, retrieving cardboard different surgical procedures that were base, staff members have to copy the medical charts from a fi ling cabinet, done? In the mid-1990’s the clinic data entered on the computers of each interpreting the sometimes messy started recording this information in of the clinic’s twelve departments onto handwriting of busy medics, and re- computerized spreadsheets using Mi- memory stick “pen drives,” walk to the cording the information in another log- crosoft Excel. The information that health information system offi ce, plug book to be added, divided, and ana- was stored at fi rst was basic: name, the drives into the offi ce’s main com- lyzed. Not only was each step of this age, gender, and diagnosis. While Ex- puter, and import the data into the cen- process time-consuming to do by hand cel is good for mathematical analysis, tral database. After 2009, the data en- but was prone to error as well. A line it is not so good for storing informa- tered by each department will in a thick logbook might be overlooked, tion. The clinic started using an elec- immediately travel via a computer net- a name misspelled, a diagnosis missing tronic database program for its medical work to be stored in a single modern from the chart, or numbers added in- inpatient department in 2000. By 2004, SQL server database. This will de- correctly. almost all of the clinic’s departments crease the errors associated with manu- Of course, even without the num- were entering information into their al information transfer, and allow the bers, the basic work of the clinic can own Microsoft Access databases, main database to be updated more continue. Medics can still see patients, which were then combined into a cen- quickly. 66 | FROM RICE COOKER TO AUTOCLAVE REGISTRATION / MEDICAL RECORDS DEPARTMENT The function of the Registration/ as to not have any incriminating evi- room for many different spelling varia- Medical Records Department is to cre- dence of their visit to Mae Tao Clinic; tions. ate, fi le and be able to quickly retrieve for others it may be that they actually Beginning in mid-2007 new pa- any one of more than 100,000 medical do not know their date of birth or even tient registrations were directly entered records. Every person coming to Mae the name of their village. For Moe Oo, into the HIS database. In less than 2 Tao Clinic fi rst goes to the Registration head of the Medical Records Depart- years, the Registration/Medical Re- Department where they are given a ment, and his staff, the diffi culties then cords Department has entered more unique registration number that will lie in translating the information from than 130,000 patients into the HIS da- follow them for all subsequent visits. Burmese or one of the many ethnic lan- tabase and is adding patients at a rate In addition to serving as the medical guages into English, which leaves of 40,000 to 50,000 each year. record for the patient, records are the source for quality assurance and case reviews. Being able to retrieve the patient records of those who, for example, had fatal outcomes from malaria or came from a specifi c area of Burma, entails identifying the patients through the Health Information Systems and then reviewing the care they received. There are formidable constraints in the Medical Records Department that are unique to a health care facility that serves migrants and displaced persons. Due to security concerns, some patients may give a different name or address on successive visits in order to remain anonymous. Others feel it is necessary to throw away their registration card before returning to Burma so Central registration department

FROM RICE COOKER TO AUTOCLAVE | 67 Providing ration to PLWHA.

HIV STORY 1992: • Home Based Care (HBC) begins workers had about the disease. Since • Mae Tao Clinic medics trained to – 15 to 40 PMTCT clients in pro- condom use was and continues to be recognize the signs and symptoms gram stigmatized, high school drop out rates of HIV/AIDS • Cotri for prophylaxis begins20 are high, and the population is very • More patients admitted to the In- • Monthly meetings of PLWA (peo- mobile, the staff feared a high level of patient Department with the comple living with aids) support group misconceptions. Even if the miscon- plications resulting from AIDS. begins ceptions were addressed, condom 1995: • MTC enters agreement with Fam- availability was limited due to constant • HIV testing introduced with the ily Health International (FHI) to economic pressure on the community. beginning of the blood donation/ provide voluntary counselling and Condoms were outlawed in Burma until transfusion program. testing and to expand perinatal 1992.21 • Rapid tests for HIV, Hepatitis B services for HIV positive women. and C, and syphilis performed at Expands services for post deliv- Facing this confl uence of public the MTC Laboratory. ery, home visits, follow-up care, health dangers, in 2000 MTC, Thai • MTC begins working with HIV and opportunistic infection. Public Health authorities, and Burma cases and referring antenatal care 2004: Medical Association conducted the cases to Mae Sot Hospital. • All testing for the Blood Transfu- HIV/AIDs KAP (knowledge and prac- 1998: sion Program sent to the laborato- tices) Survey. This was the fi rst time • HIV testing for pregnant women ry at Mae Sot Hospital. this type of survey focusing on migrant receiving antenatal care begins. workers had been conducted. The re- • Between 1998 and 2001, some fi - Prior to 1999 the clinic staff had a sults showed that the community had nancial support for the testing pro- reasonably good understanding of poor knowledge of the disease – typi- gram received, signifi cantly boost- prevalence via blood donors, antenatal cal misconceptions included the ideas ing participation to approximately and other testing; what staff members that antibiotics could prevent HIV, and 75 percent. Women’s Commis- lacked however, was a good under- that transmission wasn’t possible with sion’s support for the Reproduc- standing of what information migrant only one exposure, and community tive Health project facilitates be- 20 A preventive treatment of AIDS-related op- leaders and teachers were typically re- ginning of testing for all pregnant portunistic infections with a cheap and safe, luctant to have the sensitive discus- broad-spectrum antibiotic called ‘cotri-moxa- women. zole’, which can reduce HIV-related death rates 21 Burma: the impact of armed confl ict on chil- 2003: by up 50%. dren, p 11. 68 | FROM RICE COOKER TO AUTOCLAVE sions that HIV education entails, espe- constituting a positive step forward in convincing messages since new clients cially with adolescent students. Since preventing mother-to-child transmis- can identify with them. that time, willingness to discuss the is- sion, this program didn’t include treat- Currently, one of the major ven- sues has improved. ment of opportunistic infections, home ues for HIV testing is the blood dona- based-care, or nutritional support. tion center, with most donors being “… UNAIDS estimates that [in Burma] HIV prevalence among pregnant wom- The voluntary counselling and factory workers. Every year the clinic en is currently about 2 percent. Such a testing (VCT) program began in 2003. conducts an HIV education and coun- prevalence rate is well above the 1 per- It is a free, confi dential and anonymous selling workshop for this section of the cent benchmark that indicates a gener- HIV/AIDS counselling and testing ser- migrant population. The factories alized epidemic in which HIV infection has spread from high-risk groups to the vice offered six days a week at the work with MTC both on education as general population”… “The HIV/AIDS clinic. Partners of all positive clients well as providing blood donors. Twice situation in [in Burma] therefore has are also encouraged to go to the VCT a year MTC provides HIV counselling important regional considerations. center. VCT is a rapid test which pro- and testing for factory workers. Ulti- Pregnant women have a high prevalence rate of up to 13 percent in the ar- duces results in thirty minutes, so the mately, the factory delegates become eas of highest HIV/AIDS impact. The clinic can offer pre and post-test coun- HIV education supporters, as well as high infection rate among pregnant selling. VCT clients have a higher coordinators for blood donation. women and the lack of anti-retroviral prevalence of HIV infection than the Clearly though, the migrant and drugs imply a rapidly increasing rate of mother-to-child HIV transmission.” 22 general population since the majority cross-border communities are not com- of them present with symptoms of a posed solely of the factory workers. In From 2001 to 2003, MTC joined sexually transmitted disease, indicat- recognition of the complex demo- the Perinatal HIV Prevention Trial ing a higher risk for exposure to the graphics of these communities, MTC (PHPT), a collaborative pilot project virus. has tried to enable a peer support net- that provided no-cost testing for all an- Before the HBC program, pa- work for the migrant community, as a tenatal care patients. Blood samples tients were often lost to follow-up since means of taking advantage of opportu- were sent to the laboratory at Mae Sot there was no organized means of con- nities to network, provide HIV preven- Hospital and then combined with data tacting them. This was especially tion education, and raise awareness. from three other sites in Thailand. problematic for pregnant women who This happens through both community Anti-retroviral medications were given tested positive. The idea of HBC is collaboration as well as medical col- to those testing positive in order to pre- that by providing home visits, the clin- laboration, for example with Mae Sot vent mother-to-child transmission. ic can ensure continuity of care while Hospital. Both mother and infant received fol- increasing opportunities for counsel- Some people come Thailand to lowed up visits, and milk formula was ling on risk reduction, personal care avoid the stigmatization they would be provided to replace breast milk. Whilst and health education. The home-based subjected to, were they to be treated in 22 UNFPA, “United Nations Population Fund care staff is generally persons living Burma. At MTC, patients feel they Proposed Projects and Programs: Recommenda- with HIV who have decided they want have a safe and accepting environment tions by the Executive Director; Proposed Spe- cial Assistance to Myanmar”, 13 July 2001. UN to help others. They carry the most for treatment. MTC achieves this by Doc DP/FPA/MMR. Providing ration to PLWHA.

FROM RICE COOKER TO AUTOCLAVE | 69 providing a comprehensive approach including home-based care, nutrition support, and psycho-social services. Three medics working with the The voice of experience: HIV Peer Counselor HIV/AIDS program, Naw Shine of the Khin Lay Thwe learned that she was HIV+ in early 2004, due a test done by MTC. By the middle Blood Transfusion Program, Naw Ree of 2004, she became a peer counselor, in order to help out fellow HIV patients. She explains that of the PMTCT program and Saw Than she gets the most satisfaction from being able to talk to HIV patients when they are sick and from Lwin of the VCT and Home-based ensuring the patients and caregiver share the same outlook and approach. She travels around the Mae Sot and Cross Border area to visit her patients who may have many other problems aside Care Programs have worked for sever- from their illness. al years on their programs and are jus- tifi ably proud of the progress that has When asked about how she deals with the depressing parts of her job, Khin Lay Thwe explains been made. As a result of education her approach, “I keep in mind that everyone will die. When we do, we will be released from the suffering in this life”. She tries to explain and share this gentle acceptance with her patients and and peer support, patients are now their caregivers to bring serenity and dignity to their situation. more receptive to health education counselling and are less afraid to ask Khin Lay Thwe typically goes by bicycle to visit her patients, up to a 30 kilometer round trip over about their risk of HIV exposure. They the dilapidated roads into Burma. However, she doesn’t find this the difficult part. Rather, trying to find patients who live in jungle or unsafe areas who may be transient is the challenge. For these are proud that the patients living with cases, she takes a male friend to accompany her and ensure her safety. The other issue that trou- the HIV virus have a better quality of bled her was that many patients have difficulty accessing ARV (anti retroviral therapy). life than before. The peer-group meetings run by the HIV program have Peer counselors also provide coordination between patient and hospital. The patient may not remember what the doctor has instructed, or miss appointments. The peer counselors follow up helped patients deal collectively with with the patients to ensure they comply with doctors’ instructions, treatment, and appointment issues of stigmatization and isolation schedules. and have increased exposure to education and support. Challenges which the peer counselors cannot always address are domestic violence, family problems and financial problems, but they do their best to advise and console. While most patients are Saw Than Lwin says that when polite and cooperative, there are always a few who are difficult to manage. the VCT program started there were only about 10 people tested per month, Khin Lay Thwe plans to continue work as a peer counselor, with good health on her side for now there are approximately 100 peo- now. ple tested monthly. News has spread by word of mouth through the factories and housing areas, that at MTC, one can get a free anonymous HIV test and ing pregnant women and mothers with planning issues relevant to HIV pa- straight answers to questions. The role HIV. MTC provides milk powder, but tients are addressed in the Reproduc- the program plays in educating the HIV peer counselors need to explain tive Health Outpatient Department. community is very important, and it how to prepare and use the milk pow- Aside from addressing HIV has been highly successful in getting der. This might seem like a simple across the clinic’s programs, MTC information about HIV to the migrant task, but when the mother’s living en- aims to provide a comprehensive and community. vironment may be transient, without proactive approach to HIV. This ap- However, there are signifi cant electricity, clean water, and clean cook- proached has stemmed from the clin- challenges for the program. Patient ing vessels, it becomes a challenge. ic’s institutional knowledge that in- and staff security is a problem, particu- Thanks to the perseverance of the HIV stead of focusing on a specifi c element larly for home-based care workers. peer counselors though, there has been of HIV ( such as testing), what is need- Peer counselors do not have work per- some measureable success - testing of ed is a comprehensive approach that mits in Thailand so when they are mak- babies between 12 and 18 months after encompasses the empowerment of ing home visits they face the threat of delivery was negative for all 12 babies people living with HIV, education of arrest and detention by police; security in 2004, and for 21 of 22 tested in the community as well as working with issues are even greater for clients com- 2005. women, health workers and communi- ing to the clinic, especially from cross- The HIV program in the clinic ty based organizations. It is an ap- border areas. Moreover, many HIV/ has become integrated across depart- proach which cuts across all of the AIDS patients cannot work and there- ments, rather than existing as a com- clinic’s departments as well as partner fore do not have an income. Social pletely separate department. It is con- organizations. stigmatization of HIV/AIDS patients is ducted across blood donors in the blood also a problem in the workplace and in bank, via antenatal testing in the repro- the community. ductive health departments, family An ongoing challenge is manag- planning and counselling. Family

70 | FROM RICE COOKER TO AUTOCLAVE Medic conducts school health check. SCHOOL HEALTH PROGRAM • The School Health Program nity to prevent disease, rather than just whether the children were malnour- started in 2003, teaching hygiene and treat children after they were already ished - a special problem that affects basic nutrition to 1,500 children in 13 sick”, says Thar Win, manager of the developing brains and bodies because schools. By 2008, it expanded to serve SHP. it can cause IQ loss and physical dam- nearly 10,000 children and train 92 “The main problems seen in migrant age. He was also concerned about the teachers in 58 schools in Mae Sot, Poh children by health workers are malnu- spread of diarrheal diseases, since the Pra and Mae Ramat. Services now in- trition, acute respiratory tract and other boys had bare bottoms and played near clude vision screening, water/sanita- infections, malaria, diarrhea, worms, pots of rice and curry. Furthermore, tion assessment and monitoring, fi rst- deformities, skin diseases and anemia. Malnutrition is a signifi cant problem they were playing with live chickens, aid supplies, polio vaccination, and and teachers report that at least 50% of exposing them to the risk of avian fl u. prophylactic de-worming and vitamin children are weak because of lack of “Who are their parents?” he asked the A supplementation. food”23 teacher. Like so many others, the • School Health Teams teach age Early on, while visiting Naung teacher said the parents lived in Thai- and culturally appropriate lessons on Bo Del, a bamboo school near the Moei land illegally, had little education, and child traffi cking, child rights, HIV/ River along the border, Thar Win saw AIDS, and adolescent health, and envi- Medic monitors two little boys playing with chickens in growth. ronmental health. The teams train stu- the dirt by the kitchen. The children dent leaders, and refer abuse cases or were fi lthy. No pants, no shoes and no emergency cases to MTC; traffi cking underwear, just shirts - and laughter. cases are referred other organizations “You could see the faces, their smiles,” such as Social Action for Women he says, “but the risk around them was (SAW) too much.” Watching them, Thar Win In 2003, the Mae Tao Clinic start- worried about worm infestation, sca- ed a School Health Program (SHP) to bies and other skin diseases; tetanus prevent disease and improve health from cuts and respiratory infections among an increasing number of chil- from inhaling dust. He wondered dren displaced by war and economic migration. Teachers in newly formed 23 “Feeling Small in Another Person’s Country: migrant schools noticed students com- The situation of Burmese migrant children in ing to class with rashes, abscesses, fe- Mae Sot, Thailand”, written and published by the Child Protection Research Project of the Com- ver, and asked medics to start making mittee for the Protection and Promotion of Child school visits. “Here was an opportu- Rights (Burma), February 2009. FROM RICE COOKER TO AUTOCLAVE | 71 worked until late at night for low wages, barely surviving. They lived in crowded, damp and dirty housing without enough latrines, a bad water supply, and not enough money for food. In order to combat these types of situations, the SHP began partnering with community-based organizations to identify and improve access to clean water and latrines. The teams started annual height and weight screenings at each school and semi-annual de-worming and vitamin A supplementation. They taught children about global warming, and how to plant a garden, recycle, compost, clean toilets, pick up trash, and reduce electricity use. They trained student leaders to organize chil- Growth monitoring dren, identify problems and work to- Vaccination gether on solutions. they began teaching an age appropriate children happy, and they come to trust Has there been progress? Yes and and culturally sensitive HIV/AIDS the man. Eventually, he promises them no. As school health workers spent curriculum, along with lessons about a job if they’ll go with him. Then he more time in schools and communities, how to protect against pregnancy and forces some to beg or sell fl owers on they heard of more problems: rape, do- sexually transmitted diseases. the street, giving him whatever they mestic abuse, HIV/AIDS, child traf- In 2006, the School Health Pro- earn. Others have to work in a factory fi cking, abuse of child labourers, chil- gram joined the Burma Anti-Child for low or no wages. Still others are dren forced to porter illegal drugs, Traffi cking Network to train factory forced into sex work. This drama work with toxic chemicals and danger- workers, school staff and families teaches the children to identify and ous machinery, labor long factory about child rights and brainstorm ways avoid these dangerous situations. hours for little or no pay, or work in to prevent abuse of children. One of The key to living in this challeng- brothels as prostitutes. In response, the the most creative lessons plans they ing environment, Thar Win says, is to SHP expanded their network of partner developed is an interactive drama. learn from the children themselves. organizations, referring complicated Acting from a script, the children pre- “Even if they don’t have facilities, they cases to related organizations that deal tend to collect garbage for which they fi nd a way to play. Buddhist, Christian, with child traffi cking and abused and earn a few small coins. One day, a Karen, Burmese, Mon…it doesn’t mat- orphaned children, among others. With friendly man comes by and gives them ter the religion or ethnicity, they’ll play input from families and communities, treats to eat and drink. This makes the together because their goal is to fi nd happiness.” Of course, children have confl icts as well, but they solve them face-to-face in the moment. Adults take too long to solve confl icts, allowing them to escalate; they focus on wants instead of happiness, he says. In the short term, the School Health Program plans to expand its network of partner organizations to combat child-traffi cking and work on other health issues. Long term, Thar Win says, people need to follow the children’s example and work together to stop human rights violations in Bur- ma. Until that happens, problems will continue spilling over the border and into children’s lives. Child receives Vitamin A Growth monitoring

72 | FROM RICE COOKER TO AUTOCLAVE Patient enjoying festival (photo: Olivier Ouadah) PUBLIC RELATIONS By the late 1990’s, MTC had relocation. He coordinated with the bloomed into something more than a various departments in the clinic, as small medical clinic. The MTC um- well as with CBOs and trained a di- brella began to provide various social verse staff. Staff diversity in the PRC services, education, and community was essential in order to communicate oriented services. The medical staff in all the ethnic languages used at the began to spend more time providing clinic, as well as to have staff with direction to patients on non-clinical is- backgrounds ranging from migrant sues, drawing their focus away from communities to refugee camps. The their clinical work. At the same time, PRC was formed in 2003 in order to there were a growing number of young effi ciently communicate information people who had either arrived from to the many patients coming to Mae Burma, migrant communities or refu- Tao Clinic. Previously, patients who gee camps. These young people were needed information would simply ask articulate, energetic, and in search of the closest person to them, often a opportunities to contribute. It was a medic. This resulted in medics being natural to apply the skills of these distracted from the job at hand while young people to form a Public Rela- they clarifi ed something for the patient. tions Centre (PRC); but who could It was decided that MTC needed a pub- train them and be a leader? It proved lic relations service to ensure effective diffi cult to fi nd an appropriate leader dissemination of information and free for the undertaking, since only senior up the medics to concentrate on their members in the clinic had a good un- work. When it started, the PRC con- derstanding of security issues, how sisted of a tin roof over a concrete fl oor. partner organizations worked, and how It was responsible for taking care of the various departments in the clinic emergency patients and others who functioned. The leader would need needed assistance, and for providing good communication and organization directions and information to patients. skills. The name, “Public Relations Fortunately an ABSDF (All Bur- Centre” might be misleading, since the ma Students Democratic Front) leader PRC has a much broader role which who had plans to resettle agreed to lead includes social services coordination. the effort to set up the centre until his These services include: providing in-

FROM RICE COOKER TO AUTOCLAVE | 73 as emergency patients, and it brings food to patients in IPD and Child IPD who cannot get their own. Another of the PRC’s responsibilities is the care of patients who are at the clinic long-term, such as the mentally ill, the elderly, and formation to clinic patients, keeping the disabled. The PRC also organizes pital. Patients were failing to follow- records of vehicle traffi c at the clinic the distribution of the clinic’s mail to up because they had traveled back for security reasons, assisting patients the appropriate departments. home and could not afford, or did not who are frail or cannot walk and caring U Tin Shwe, the head of Public have the time, to return to the clinic. It for long-term patients, such as the Relations, says there are many chal- was decided that housing them at the mentally ill and the elderly. It also runs lenges for the department. For in- clinic would increase the likelihood of the clinic’s patient house and funeral stance, they often have to help migrant patients staying and thus receiving bet- service. Many who visit the clinic de- workers whose bosses have simply ter health care. scribe it as a “little village” – the PRC dropped them off at the clinic with no Funeral Service: Mae Tao Clinic ensures that the environment is clean, means of returning to their place of organizes funeral services for patients organizes festival events, and works to employment. The PRC will try to get whose families cannot afford the ser- make the clinic a safe and culturally in touch with the employer, and if that vice, cannot be contacted, or cannot rich place where patients can recover. fails they will give the patient money make the journey to Mae Sot to claim The PRC is also frequently the fi rst for transport. U Tin Shwe says that de- the body. Most services are either Bud- point of contact for emergency medical spite obstacles, there are also many up- dhist or Christian, and involve either patients arriving in the clinic, or those lifting moments and his proudest cremation or burial. requiring referrals to other social ser- achievement is helping patients every- U Tin Shwe is always sad to see vices. day. If he could have anything for the patients who have died with no family Today, the PRC has a small offi ce department that he wished, it would be around. He recalls one particular pa- added onto the original enclosure, and an ambulance like the Thai hospitals tient who had an impact on him, a 28- has a plethora of new responsibilities. have. He would like to drive it around year-old man who was HIV positive. In addition to providing information, to pick up patients who are too ill to He often came to the clinic for treat- they now also take care of MTC secu- travel and need transport to Mae Tao ment, and one time he was admitted to rity. This involves recording the num- Clinic. IPD with severe malaria. The clinic ber plates of cars that come through the Patient House: The Mae Tao tried to contact his family, but could clinic, both for security reasons and to Clinic patient house was built in 2004 not get in touch with anyone before the keep track of who has come in with pa- to address an increasing need to house patient died. Although U Tin Shwe tients in case of emergency. The PRC patients who were awaiting follow-ups fi nds such situations challenging, he is also has stretchers to tend to patients or referrals to a Thai hospital, such as happy that he can at least offer some who are frail and cannot walk, as well Mae Sot Hospital or Chiang Mai Hos- dignity in death to patients like this.

Patients enjoying festival (photo: Olivier Ouadah)

74 | FROM RICE COOKER TO AUTOCLAVE Medics conduct dental hygeine in School Health Program. DENTAL CLINIC What to do if your molars ache, rate department in a newly constructed canals, 87 scalings, 289 resin fi llings gums swell and the shooting pain in concrete suite that has three donated and treated 18 oral cancer patients for your jaw keeps you awake at night? If chairs and high-speed pneumatic den- pain. you’re poor and from Burma, you head tal drills. Led by clinical supervisor Almost all the patients seeking for the Mae Tao Dental Clinic (MTDC), Dr. Kyaw Zayar , a dentist from Burma, dental care at the Mae Tao Clinic have where trained dental workers examine, and clinic manager Gay Moo , the 6- never before visited a dentist. In addi- diagnose and, when necessary, drill person staff is specially trained in den- tion to their primary complaint, eight and fi ll cavities, scrape away plaque, tistry and sees 20 to 30 patients daily, out of 10 patients also have cavities perform root canals and extract infect- resulting in the treatment of approxi- they aren’t aware of. The problem, ed teeth - for free. mately 4,000 patients in 2008. In the dental medics say, is that most patients fi rst half of 2008, the dental clinic per- have little education and don’t under- Dental Clinic saw about 4,000 patients in formed 1,907 tooth extractions, 26 root stand the importance of oral hygiene. 2008, and extracted 1,907 teeth in the first half the year alone. “Dental care is very important,” says medic Lawkwa . “It is a part of health. The Mae Tao Dental Clinic start- Before, people didn’t understand. They ed in 2001, opening three days a week only (associate) malaria and diseases as an adjunct to the clinic’s surgery de- like that with health. [A tooth infec- partment. At fi rst, the clinic had only tion] starts because of lack of knowl- one syringe and a handful of dental edge about how to clean and take care mirrors and tools for extractions. The of the mouth. It gets worse, sometimes surgical medics, who had attended a turning into an abscess if you do not dental training in Bili Htoo, saw three get appropriate treatment. Lots of suf- to fi ve patients a day. Patients came to fering, pain, fever. It can cause osteo- the clinic complaining of tooth pain, myelitis, an infection of the bone.” jaw swelling and abscesses. Some- For impoverished patients, it’s times the medics couldn’t fi gure out common to delay treatment until an in- what caused the problems, but they fection rages out of control. Patients could treat the symptoms by cleaning say they’d be forced to spend their life teeth, giving antibiotics, draining ab- savings if they went to a doctor or den- scesses, and, when needed, extracting tist in Burma, so they wait, hoping the teeth. infection will clear up by itself. “It’s Today, the dental clinic is a sepa- Dentist working in clinic. not a problem for the rich man,” Lakwa

FROM RICE COOKER TO AUTOCLAVE | 75 says, “but it’s a BIG problem for the Dental medic examines patient. daily workers and the poor people.” When the dental medics ask why patients didn’t come earlier, “Most of the patients say they can’t leave their work, they have no transportation, they have no money. So the dental problem gets worse and worse,” according to Lawk- wa. The medics recall the sad story of a 9-year-old girl whose father brought her from Burma with a fever and swol- len face caused by an infected tooth. The dental medics wanted to admit her to the pediatric ward, but her father needed to return Burma to farm. So they gave the family antibiotics and asked them to come back for follow- up. By the time the girl fi nally returned, the bacteria had spread to her bloodstream. They sent her to Mae Sot Hospital, but it was too late; she died of fi lling. They asked her to return in a Through the School Health Program in septicemia. week for the permanent fi lling - enough 58 migrant schools, the medics tour People struggling to earn enough time for the calcium hydroxide to kill schools with colorful posters showing to feed themselves can’t risk losing bacteria and for the swelling to de- healthy food (fi sh, vegetables, fruits) their jobs. Yet many employers decrease. But she didn’t have another and unhealthy food (candy, ice cream, mand long hours from their workers, day off for two months. If she left Coke) choices. They warn children not giving them only one day off every 60 work to return before then, she risked to chew betel because doing so chroni- days. This makes it nearly impossible losing her job and getting arrested cally increases risk of oral cancer, a to go to the dentist when necessary. An without a worker I.D. (which her em- painful disease that causes swelling example is a young woman who came ployer held). There was nothing to do and ulcers inside the mouth and can to the dental clinic during the holidays but wait two months and hope for the lead to death. In 2007, the dental clinic with a toothache so painful she could best. diagnosed more than 20 cases of oral not eat or sleep, causing exhaustion The dental medics know preven- cancer, but because treatment is be- and weight loss. The medics found a tion is the best treatment. They hope to yond the clinic’s resources, it could of- very deep cavity. They performed a improve oral health by teaching chil- fer these patients only pain medica- root canal, cleaned the area with calci- dren the importance of brushing their tion. um hydroxide, and put in a temporary teeth and avoiding sweet foods. Over the years, the Clinic developed its dental services with support, Medic teaches children about dental hygeine. technical training and donations from generous volunteers, including Dr. Mi- chael Travis from Colorado, who has visited the clinic annually since 2004 and donated much of the machinery, fi lling materials and instruments; and Dr. Bo-im from Korea, who trained the medics to clean and scale teeth and perform root canals in 2008. The dental medics dream of offering x-rays and dentures at the clinic someday. Their short-term wish list is for small dental instruments, an atlas color endodontic book and a dental surgery book so they can learn more and provide better care.

76 | FROM RICE COOKER TO AUTOCLAVE PARTNERSHIPS: 2000 - 2004

BURMESE MIGRANT the Thai education system in this case. As elaborated in the Child Protection WORKERS chapter of this book, CPPCR created EDUCATION an innovative program to create delivery certifi cates and birth records. This COMMITTEE work has been done in the true spirit of (BMWEC) public-private partnership, with the Thai government, community based Starting about ten years ago, organizations, and MTC. community based organizations started to collaborate and work together along the border areas. BMWEC is a refl ec- ADOLESCENT tion of that strong community engage- REPRODUCTIVE ment, an umbrella organisation of 45 HEALTH NETWORK schools. Each school is represented by their headmaster in BMWEC, giving a ARHN is also a refl ection of the voice to all in the community. strong collaboration among communi- BMWEC continues to work to ty-based organizations along the bor- strengthen both education as well as der. The fi rst collaboration began in overall situation of migrant and IDP 2000 with Social Action for Women children. One example is a pilot proj- (SAW), Karen Women’s Organization ect with the Thai Ministry of Educa- (KWO) and MTC. ARHN is now a tion, which aims for providing accredi- network of organizations including, tation of migrant schools by the Thai but not limited to Karen Women’s Or- government. Other important areas in- ganization (KWO) , Social Action for clude advocacy and the creation of a Women (SAW) , Palaung Women’s Or- child protection policy. ganisation, Karen Youth Organisation (KYO), Burmese Women’s Union, and COMMITTEE FOR NLD Women. Usually the health organizations THE PROTECTION develop maternal and child services AND PROMOTION which are clinic based. Unfortunately, OF CHILD RIGHTS this approach doesn’t integrate with youth, men or other members of society. Therefore, the ARHN has devel- A major issue for migrant chil- oped effective outreach to all parts of dren is statelessness. In some coun- society. Cultural and reproductive tries, migrant children are migrant with rights information is provided to a identity in their home countries. The broad population base in a culturally situation is more complicated when appropriate manner. In the past, ac- children do not have identity in any cessing reproductive information for country, which denies them access to young people was, at best stigmatized

FROM RICE COOKER TO AUTOCLAVE | 77 or at worst, not possible. By working displaced women from Burma who are with an imperforated anus. Mae Sot both within the schools and outside in crisis situations after having fl ed to Hospital had done a colostomy on him schools, the outreach is available for Mae Sot, Thailand. SAW is based in at birth, the fi rst of three surgeries nec- students and non-students alike. This Mae Sot and was established to sup- essary to repair the problem. However, approach provides the opportunity to port women facing diffi culties through the boy’s family could not afford the discuss gender equity, youth participa- the provision of shelter, health educa- second or third surgery needed to oper- tion, peer support networks, self-es- tion, rights awareness, counselling, and ate on his anus and remove the colos- teem, and raising awareness on issues vocational training for unskilled wom- tomy. Without the surgeries the boy’s such as unsafe abortion. en. life would be diffi cult, needing to con- The ARHN conducted a survey In addition to working in partner- tinually manage a colostomy bag in of adolescents in migrant, internally ship on health education, SAW steps in less than sterile conditions. The boy displaced and refugee populations.24 to assist when babies are abandoned at needed to go to CMH for surgery and They developed training curriculum the clinic. SAW arranges for safe ac- Kanchana made sure that he received together and conduct trainings with commodation and care for these chil- the necessary treatment. adolescents in these target populations. dren in their facilities. The BCMF referral program de- Topics include gender based violence, pended on the support of volunteer sexually transmitted infections, family doctors, so as the doctors’ began fi nish- planning, and leadership skills. BURMA CHILDREN ing their placements at MTC more and MEDICAL FUND more children’s needs for surgery went unmet. In 2006, Kanchana, now faced HUMAN RIGHTS Since 2006, the BCMF program with an increased demand for surgery EDUCATION has helped 300 patients and the withdrawal of volunteer medi- INSTITUTE OF The largest number of cases re- cal assistance, decided to fi nd donors ferred involves those with congenital and get commitment from Thai hospi- BURMA heart problems tals that would ensure the long-term Patients need from one to as many sustainability of the BCMF program. Human Rights Education Insti- as fi ve referral trips, depending on the Kanchana revitalized the BCMF pro- tute of Burma (HREIB) was estab- severity of their illness and the number gram, restructuring its management, lished with the mission to empower of surgeries they require. and creating a more sustainable sys- people through human rights education At Mae Tao Clinic, there are pa- tem. The result was a fund that cov- to engage in social transformation and tients whose needs go beyond the ered all complex children’s cases, en- promote a culture of human rights for available services. Many of these cases suring these children received the all. HREIB has worked in partnership are curable and if treated, would have life-saving treatment they needed – with MTC through training and facili- life-changing or life-saving results for heralding a new beginning for the tation. HREIB has conducted training the patients. The necessary surgeries BCMF. on child rights and human rights, with or treatments are inexpensive by west- BCMF has been successful in emphasis to “train the trainer” in the ern standards, but are often too com- supporting 300 complex medical cases community migrant schools. HREIB plex and expensive for Mae Tao Clinic also played an important role in the to support. In recent years, visiting participative process of creating a child doctors to the clinic would often fi nd protection policy by providing facilita- outside support for children requiring tion of the process with many commu- extensive treatment either at Mae Sot nity based organizations. HREIB also Hospital (MSH) or at Chiang Mai Hos- tirelessly campaigns for child and hu- pital (CMH). This was helpful, but man rights. was done on an ad hoc basis, and the needs of many of the child patients SOCIAL ACTION went unmet – sick children had to be sent away without the treatments they FOR WOMEN needed to live. In 2003, a volunteer critical care Social Action for Women (SAW) nurse, Kanchana Thornton’s fi rst case was founded in June 25, 2000 to assist while working with this fl edgling referral program, known as Burma Chil- 24 “Protecting our Future: A report on adoles- dren Medical Fund (BCMF), was a 5- cents’ knowledge, attitudes, and practices related BCMF patient to reproductive health & rights on the Thai/Bur- month old baby who had been born ma78 | FROMBorder” RICE Released COOKER TO June AUTOCLAVE 16, 2009. Kanchana negotiated with the Thai authorities to create a system between MTC and the relevant Thai security forces, allowing for BCMF to organize, since 2006, with approximately 140 prepare and coordinate the appropriate child when he was unwell and could still active cases. In 2008 the program paperwork for the transfer of patients not work. His father was 23 and he also began supporting treatment for to Chiang Mai. Without this generous stayed at home in their village in Bur- special adult patients. BCMF supports support and understanding of the Thai ma. The family is from Nyinaung, a these patients all the way through their authorities, especially local police and small village of only 700 houses, where medical treatment, and provides coun- the military, the referral program would there is not much work; often his father selling and social welfare assistance to not be possible. As regional and local had to leave the village for days at a make sure patients get back on their politics change, it is essential to main- time to fi nd work. Without surgery San feet. BCMF also provides medication tain regular contact with authorities to Nyein Aung would have died. and equipment, in the form of wheel- ensure the future of the BCMF pro- San Nyein Aung fi nished his fi nal chairs, special footwear, and mattresses gram. surgery in November, 2008. His grand- to maintain and improve patient’s qual- In late 2008, an INGO called mother accompanied him for his fi nal ity of life. In the unfortunate event that Child’s Dream began supporting the treatment as his parents needed to keep a patient dies, BCMF supports the fam- complex cases at MTC’s for patients working to support the family. Thanks ily, helping to organize burial or cre- under the age of twelve. As a result, to the operation, he has much more en- mation services. With a focus on re- BCMF has turned its attention to se- ergy and is very playful. His grand- spect and dignity, BCMF ensures that curing funding for treatment of those mother says that he is now full of chat- the patients’ right to health - a basic hu- patients over twelve years of age. In ter and talks a lot. The family plans to man right - is fulfi lled. 2009 work continues to further develop send him to school next year and hope To get the program to where it is an adult referral program under the that he will now go on to get an educa- today has not been easy. The process name of the Burma Adult Medical tion and eventually go to high school. of coordinating a patients’ referral to a Fund (BAMF). Kanchana says that all Their main wish however, is that he medical specialist can be complicated. of the challenges have been worth it. will grow up healthy so that he can do Although some treatments can be done “If you put in a little effort for the kids, whatever he wants when he is older. in the nearby Mae Sot Hospital, the the rewards are amazing.” To be able His grandmother expressed her deep majority of treatments need to be done to give a child a future, to see the en- gratitude to the donors who made his at Chiang Mai Hospital, 400 kilome- ergy restored to their bodies, to see the surgery possible, as well as to the clinic tres from Mae Sot. Coordinating the look in the eyes of grateful parents – it and BCMF. When the staff asked San referral of Burmese patients to a Thai is all worth it, she says. The patients’ Nyein Aung how he feels now that he hospital requires not only the goodwill families do not have the money to pay has had surgery he starts to sing! What of Thai authorities but also a coordi- for the services, yet they fi nd ways to could express it more perfectly than nated, cooperative effort from MTC thank the BCMF program for saving that…… and BCMF staff to ensure patients their children. Saw Win, the father of While San Nyein Aung’s story is make it to specialist appointments, and the young patient with the colostomy that of just one boy, it is also in a way, are able to return for follow-up care. calls twice a year to give an update on the story of every patient that has been Additionally, transporting pa- how well his son is doing and to say treated, and who has come through tients to CMH is not easy. Most of the thank you once again. Mae Tao Clinic. BCMF has treated patients are in Thailand illegally and The future aims of BCMF and the many patients whose stories, while all do not have the proper documents to BAMF are simple – to secure more individual, have a common thread; travel through the various Thai security funding in order to provide more life- which is that without the BCMF’s sup- checkpoints between Mae Sot and Chi- saving and life-changing treatments for port these kids would have surely died, ang Mai. Most of MTC staff also lack the people coming to Mae Tao Clinic or lived severely diminished lives, as the necessary paperwork to escort pa- for help. there is no way their families could af- tients to Chiang Mai. Before the for- San Nyein Aung (Sam), was 13 ford their much needed surgery, let mation of BCMF, MTC was dependant months old when he came to Mae Tao alone navigate the plethora of security on INGOs for patient transfers to Chi- Clinic in early 2006 with a heart prob- issues they would have had to over- ang Mai. This however, did not result lem. His heart was twice the size it come to get to Chiang Mai Hospital for in a reliable or sustainable option. should be and he only weighed a frac- their surgery. tion more than the average newborn. His mum was 22 and she had spent most of the last year looking after her

FROM RICE COOKER TO AUTOCLAVE | 79 2005 – 2009: THE SCOPE BROADENS

Mae Tao Clinic today.

80 | FROM RICE COOKER TO AUTOCLAVE REFUGEE DOCTOR ‘MAKING A DIFFERENCE’ FOR THOUSANDS IN BURMA

authorities, they do not exist. who can, pay under a dollar. But to Dr. Cynthia Maung, they Dr. Cynthia lives in modest quar- do matter. Dr. Cynthia is a Burmese ters next to the clinic. She could have physician and a refugee herself. She immigrated to the West and be making makes a difference for thousands of her a huge salary. But for Dr. Cynthia, this fellow refugees in Thailand and for is a greater calling. many more inside Burma. For exam- “When we live here, we are not ple, the Burmese physician founded only treating illnesses, we can also ed- the Mae Tao Clinic, a safe haven where ucate young people who can go back miracles happen every day. and work in their community and who Dr. Cynthia fl ed Burma in 1988 are very willing to promote the health following an army crackdown on those activities in their village. So it is a very who demonstrated for democracy and good opportunity for young people to Dr. Cynthia Maung justice. give education and to give more hope,” Thousands of people fl ee Burma “I joined with the demonstration she says. each year, escaping poverty, oppres- group and then when the military The clinic trains volunteer med- sion, and civil war. The nearest escape seized power, people started disappear- ics who fan out into the ethnic Karen for most is Thailand, where they expe- ing, or missing, or fl ed to the border. I and other isolated areas of Burma. rience both despair and hope. Burmese myself also decided to come to the bor- Some of the volunteers are former pa- refugee, Dr. Cynthia Maung, runs a der to continue struggling or working tients who, once desperate for help, are small, modest public health clinic near for political change,” she says. now the ones helping. It is they who

A mother and child visit Dr. Cynthia Maung’s clinic. A patient receives treatment the border in Thailand, and is making a In a two-room shack, she started embody Dr. Cynthia’s vision. difference in her community by pro- doing amputations and delivering ba- The Burmese physician says viding essential services not available bies using instruments sterilized in a young people should be taught “not to to most residents of the poor region. rice cooker. Young volunteer medics feel as victims.” Instead, she says, they Mothers line up with children, trained by Dr. Cynthia treat everything should see themselves as “people who waiting for immunizations. In another from landmine injuries to gastroenteri- can change or improve the situation.” line, couples with newborns wait for tis. With donations from NGO’s and Dr. Cynthia is reviled by Burma’s documents certifying their children foreign governments, including the military government. To the generals, were born in Thailand. The documents United States, Dr. Cynthia’s work has a she is a terrorist and an insurgent. To take the place of birth certifi cates Thai- reputation for a making a little money the thousands she treats and trains, she land refuses to issue. These people are go a long way. Each year 150,000 peo- is a saint. refugees, and in the eyes of Thailand’s ple come here for treatment. Those VOA News, 2008 (photos: P. Laput) FROM RICE COOKER TO AUTOCLAVE | 81 HEROIC EFFORT: Youngster plays mum. (photo: Phil Thornton) FOR CHOO, IT'S ALL WORK AND NO PLAY The people of Burma are used to suffer- welfare of both children. sick, she went to the toilet all the time. ing. Burma has the worst health record "I'm worried they have no moth- She couldn't get better. She took medi- in Southeast Asia. Yet the regime is not without money. It siphons billions of er. I'm worried that a 12-year-old, car- cine, but nothing worked. She died." dollars earned from natural energy re- rying a seriously sick infant, had to May Soe said Choo's mother sources into offshore accounts while its travel so far without the protection of probably died from complications re- citizens are forced to seek health care in an adult." lated to dysentery. neighbouring countries May Soe says getting to the clinic "If she could have got treatment, It's mid-morning on the Thai- from inside Burma is diffi cult for adults it would have been preventable." Burma border and amid the constant at the best of times. Dr Voravit Suwanvanichkij, a refl ow of people pouring into Mae Tao search associate at the John Hopkins, Clinic looking for health care is a bare- "It took the kids at least six hours Center for Public Health and Human foot girl carrying a feverish infant, half to get here from their home. There are Rights, and one of the authors of the her own height. many army checkpoints to get around. report The Gathering Storm: infectious The girl, Choo, shuffl es and push- There are many people who take ad- disease and human rights in Burma, es her way to the front of the long vantage of children. Choo had no mon- not only agrees with May Soe, but also queue that stops in front of a white- ey and no one to help. The kids arrived condemns the Burmese military regime coated medic in the Children's Outpa- with only the clothes they were wear- for failing to protect and provide the tient Department. ing." Burmese people with access to basic May Soe, the senior medic and Choo explained to Spectrum why health care. manager of the department, looks up she came to the Mae Tao Clinic: "Wai "It's not just a tragedy - I would and asks: "Where's your mother?" was sick for fi ve days. She was hot, go further and call it a crime. The Choo hitches the slipping child crying all the time. There was no mon- mother's death was preventable." onto her hip before saying: "Ma's died, ey to get medicine. I was worried, I The Mae Tao Clinic was set up by I'm mother now." was scared, I thought she would die Dr Cynthia Maung in 1989 to treat May Soe was shocked by Choo's like Ma did if I didn't take her to Thai- Burmese people along the border, and response, but did not have time to take land. Many people in the village told each year its caseload increases. it further, as the infant needed urgent me to take her to Dr Cynthia's." In 2006 the clinic saw 107,137 medical assistance. When Choo left home it was still people who needed help. "Choo's baby sister, Wai, was early morning. In 2008 this had jumped to very sick with malaria, she was dehy- "It was dark, no lights, the sun 140,937. May Soe says the 13,438 drated and also anemic. She urgently was sleeping." children seen by Child Health in 2008 needed a blood transfusion and we had Choo tells how scared she was were mainly the result of acute respira- to get her onto a saline drip." when her mother died two years ago. tory infections, malaria and anemia. May Soe is concerned about the "Wai was six months old. Ma was In spite of the increased numbers 82 | FROM RICE COOKER TO AUTOCLAVE der State Fundamental Principles, clause 17 (a) is this passage: "The state shall earnestly strive to improve education and health of the people." But the constitution principle rings hollow when subjected to closer scrutiny. coming to the clinic in search of health Dr Voravit says Burma's health baht) per capita. care, Dr Cynthia says she expects to indicators are amongst the worse in the A John Hopkins School Of Public have less money in 2010 due to donors region. Health report, The Gathering Storm, pulling out. "Burmese people are coming to estimates that the Burmese regime "We estimated a shortfall of about Thailand for basic health care. People spends as little as "3% of national ex- US$350,000 (11.6 million baht) in in Burma are dying because there's no penditure on health, while the military, 2009 and US$750,000 in 2010. We've signifi cant investment in health infra- with a standing army of over 400,000 always been funded year by year. This structure, no access to the most basic, troops, consumes 40%". short-term funding only allows you to cost-effective health interventions that Dr Sean Turnell from Macquarie breathe for a short while." should be available at home. Over 7% University in Sydney, in a report, Bur- Dr Cynthia says her ever-increas- of Burmese children don't survive to ma after Nargis, accuses the regime of ing patient caseload is dictated by pov- their fi rst birthday and 10% will die be- squirreling away revenue earned by the erty, military oppression and the lack fore their fi fth." sale of national resources such as oil of human rights in Burma. Dr Voravit says these statistics and gas to off-shore bank accounts for "The poor in Burma are getting are proof of years of neglect, and con- their own use. poorer. We are not only treating mi- trary to the regime's claims, clearly "Burma currently receives be- grants and refugees, but people from demonstrating how Burma's health tween $1 and $2 billion a year from its the cities and deep inside Burma. Over system has failed its people. sales of natural gas to Thailand, but the past 20 years I have never seen the According to a health report, these funds are kept far from the coun- patient caseload decrease. Chronic Emergency, by the Backpack try's public accounts." "I worry for next year - at the mo- Health Workers Team, an organisation Dr Turnell says the funds are ment we don't have enough money for that delivers medical assistance to dis- moved off-shore and accessible only to medicine, food, child protection or placed Burmese people, the situation the top leadership lurking in the shad- training." in eastern Burma is more dire. There, ows of the regime's State Peace and Dr Cynthia says all groups work- one in 10 children will die before age Development Council. ing on Burma's problems face the same one, and more than one in fi ve before "Burma's gas earnings are today challenge - getting the regime to em- their fi fth birthday, and one in 12 wom- employed in constructing the country's brace change. en will lose their lives from complica- new jungle capital of Naypyidaw, in "I don't expect to see any notice- tions of pregnancy and childbirth. buying military equipment from China, able change in Burma in the near fu- Dr Voravit says these fi gures are and in funding other schemes and pro- ture." comparable to disasters in such places clivities that have long characterised Meanwhile, in recent months, the as Rwanda, Democratic Republic of the often bizarre aspects of the coun- Burmese regime, in an attempt to get Congo and Somalia. try's policy-making processes." international trade sanctions lifted and Dr Voravit's damning facts are Matthew Smith from Earth Rights their hands on large sums of aid money, supported by an overwhelming number International says Burma earns billions has pointed international governments, of international reports, including those from its natural resources. humanitarian agencies and non-gov- from the United Nations and the World "Since 2000 the Yandana gas ernment organisations to their self- Health Organisation. project has generated $7 billion in rev- lauded, but much-criticised National The UN's Development Pro- enue. But a massive $4.83 billion bye- Constitution, as proof that they are se- gramme's Human Development Index passed the rightful benefi ciaries, the rious about building a fairer society. ranked Burma 130 out of 177 coun- Burmese people, and ended up under Enshrined in the constitution, un- tries. The World Health Organisation the control of the military." placed Burma's health system as the world's second worst out of 191 countries. Burma's offi cial spending on health per capita is estimated to be $0.74 (24 baht) compared with its Thailand, which invests $89 (2, 955

FROM RICE COOKER TO AUTOCLAVE | 83 While the regime plunders money Since her mother's death two years ago, meal ready. rightfully belonging to the Burmese Choo has not attended school, she now "Sometimes I get sick and I need people', Choo's father, a daily labourer has to look after fi ve children younger to rest. If the others have time they help when he can fi nd work, earns 3,000 than herself and manage the household me. When I have free time I like to kyat a day, or less than $3. UN agen- for her father and stepmother. play." cies say 73% of the average Burmese "When everyone is at work I look Choo says she misses school. "I household budget is spent on food after fi ve children. I also cook for ev- had to stop when Ma died, but I miss alone, making Burma one of the worst eryone. I get up when it is still dark to Ma more. When Ma was here, life was food-insecure countries in the world light the fi re and fetch water for cook- easy. If Ma was here, I would be able to and one third of Burmese children suf- ing." go to school and play. I miss her cud- fer from malnutrition. Choo cooks six kilogrammes of dles and kisses. Dr Voravit says: "A result of this rice a day. She has to split the cooking "I like to play and read when I is that for most Burmese families, ba- into three sessions as the combined have time. I love all my brothers and sic health care becomes an unafford- weight of water, pot and rice are too sisters, but I fi ght with my new [step] able luxury." heavy for her to lift. "I'm not strong. I brothers and sisters. But it is not only wage earners in look after all the other kids until after "I'm happy here at the clinic, Burma who are paying the price for the six at night when Pa and the older ones plenty of people help me, May Soe regime's military-inspired policies. get home. I have to get the evening gave me and Wai clothes." Choo runs

around trying to help older women Choo is not shy. "She's liked by the Choo's very good, but she's vulnerable, carry their food trays and pulls funny other patients, she helps where she can. she's a baby looking after a baby." faces to make the other children in the I look at my 11-year-old daughter and I ward laugh. can't imagine her doing this. I'm happy by: Phil Thornton, Bangkok Post May Soe, a mother of three, says she only has to think about playing. 2009

84 | FROM RICE COOKER TO AUTOCLAVE six months were very slow, as neither patients nor staff had a strong understanding about what counselling services were, who should be accessing them, and the incredible benefi ts that they could have. Also, there was the challenge of staffi ng the centre, as the newly trained counselling staff continued their work in other departments of the clinic, which were often busier and seen as a priority. These challenges instigated the development of the Department Aware- ness Program, wherein staff members from other clinic departments are invited to the Counselling Centre for one-hour information sessions. The counselling staff explains the services available at the centre, the great benefi ts of these services, how and when to refer patients, and when staff should COUNSELLING CENTRE visit the centre themselves. The counselling staff continues to run the De- For the displaced Burmese popu- these mental health care skills to the partment Awareness Program, which lations living along the Thailand-Bur- organizations working along the bor- has successfully led to the continual in- ma border the ongoing experiences of der was certainly benefi cial, but with crease in the number of patients ac- socio-economic struggle, physical and the population of displaced Burmese cessing the Counselling Centre. psychological trauma, endless human people continuing to grow, and more For those requiring psychosocial rights abuses, chronic illness, exploita- and more people accessing health care assistance, the Counselling Centre pro- tion as migrant workers, and being tar- at MTC, more needed to be done to ad- vides incredible support, but at times, geted for human traffi cking have re- dress the increasing psychosocial due to insurmountable obstacles, the sulted in many psychosocial challenges. needs. Both staff and patients of the outcomes sought by both patients and As the population living along the clinic needed greater psychosocial sup- counselors are not always attainable. Thailand-Burma border quickly grew port – they needed confi dential coun- Saw Than Lwin explains the challeng- throughout the 1990s, it became evi- selling, in a private space, from coun- es and frustrations of not always being dent to Dr. Cynthia and other commu- selors with more advanced skills. In able to help all of the patients they see, nity leaders that psychosocial support response, preparations began in 2004 “Some patients come with social prob- was needed for this population. for the development of a separate lems related to natural disasters or In 1999, a Mental Health Coun- Counselling Centre at MTC. chronic diseases, where their commu- selling Training was coordinated A new building was constructed, nity no longer accepts them. We can- through the assistance of international providing a space for the Counselling not provide social services, like fi nding organizations, for 32 participants in- Centre as well as the HIV Voluntary work and places to stay.” He also re- cluding MTC medics and schoolteach- Counselling and Testing Program. called the story of a patient who had ers, as well as individuals from other Further training sessions were con- been suffering from stress and depres- local organizations. This was an intro- ducted, providing basic knowledge and sion as a result of not being paid by the duction to the basic concepts and tech- skills in mental health care, as well as factory owner he worked for. “How niques of mental health care. The fol- tools for specifi cally addressing the are patients supposed to address prob- lowing year, a Child Psycho-Social now endemic psychological trauma. lems like this when a complaint to the Training was conducted, for 32 partici- In 2006, mental health services became authorities is risking arrest and depor- pants from MTC and other local orga- part of the primary health care offered tation back to Burma?” In these cases, nizations, focusing on basic principles at Mae Tao clinic, with December 6th the counselling staff rely on their com- of childhood behaviour and develop- marking not only Dr. Cynthia’s birth- munity networks, referring patients to ment, children’s rights, and program day, but also the offi cial opening of the other organizations such as the Migrant development to enhance children’s Counselling Centre. Program Manag- Assistance Program (MAP) for labour mental health. The introduction of er, Saw Than Lwin recalls that the fi rst issues, or Social Action for Women FROM RICE COOKER TO AUTOCLAVE | 85 (SAW), for women and children escaping abusive environments, who need a safe place to stay and access to income generation and education opportunities. In the future the Counselling Centre hopes to further expand these invaluable community networks. There are plans to conduct regular Community Awareness workshops, where other organizations providing social services will be invited to learn about the services of the Counselling Centre, and to share information about their own services. Saw Than Lwin views this as an opportunity to ultimately help more patients, by either referring them to the appropriate organizations or eventually offering services that are not already provided by another organization in the community. As the Counselling Centre is still a relatively young program, the immedi- RESEARCH ate future will also involve further Research at MTC is a refl ection Initially, research was done when skills training and capacity building. of the evolution of MTC as a whole, external organizations were able to International volunteers, of various evolving from service provider into provide resources and expertise. How- mental health backgrounds, have program manager, community orga- ever, MTC has been increasing the pro- played a large role in the development nizer and advocate. Initially, there was portion of internally based research of the center, providing regular mental only medical action-oriented research, projects with the aspiration to improve health training programs that have been focused on medical treatment out- areas such as program design and poli- tailored to the specifi c needs and re- comes. Today, the goals of research cy. Over the years, clinic staff was able quests of the counselling staff. The lo- touch upon program development and to learn from others who conducted re- cal staff is eager to further develop assessment, resource allocation, per- search as partners. Research was fi rst their skills, to understand how other formance monitoring and broad-based introduced in the clinic in 2001 through countries work to support citizens who understanding of community health the reproductive health monitoring are suffering psychosocial problems, care needs. evaluation project. This project helped and to transfer their gained knowledge Since the clinic patient popula- the clinic staff to develop an under- to supporting fellow Burmese people. tion is predominated by migrant work- standing of how to conduct research Even though the staff express a ers in Thailand and IDP populations in and to utilize the fi ndings. The benefi ts need for further training, they are able Burma, it is important to understand included improved clinical assessment to celebrate the positive effects already these populations for the purpose of ef- skills, facilitating peer supervision seen at the Counselling Centre; Saw fective program design. However, as through case review, an increased abil- Than Lwin says that, “We are very noted by the European Union, “Wheth- ity to demonstrate program effective- proud of our experiences. Some pa- er internal or cross-border, both forced ness, ability to promote cultural ex- tients are completely better after their and voluntary (economic) migrations change through enhanced counselling treatment. It makes us very happy to occur on a relatively substantial scale. skills and increased issue awareness work through their problems, to under- However, data collection on the differ- for adolescent health, sexual health, stand their feelings.” To further de- ent types of migration is almost non- gender based violence and mental velop this department will increase the existent…. Economic migration is a health. The success of this research en- invaluable psychosocial support being diffi cult phenomenon to grasp in Bur- couraged collaboration on future Re- provided to the displaced people of ma/Myanmar, due to large inaccessible productive Health projects. Burma, giving them counselling, cop- parts of the country and migrants’ fear When MTC did begin doing in- ing techniques, and possibly a renewal to tell their story”.25 ternal research the areas of most im- of hope. portance were communication, Sexual 25 The EC-Burma/Myanmar Strategy Paper and Gender Based Violence, and clinic (2007-2013) P 37. 86 | FROM RICE COOKER TO AUTOCLAVE staff. For the Mae Tao Clinic, research nator, Saw Aung Than Wai laments this accurate monitoring over longer peri- is an opportunity to gain accurate in- situation, “They just don’t know how ods of time is required. The less formation about the health situation on useful the information could be.” straightforward areas include monitor- the Thailand-Burma border. Unable to MTC participates in many collab- ing complex reasons behind patient de- rely on the Burmese military junta for orative research projects done in part- cisions regarding how and when to ob- accurate information, the clinic has nership with other local and interna- tain health care, along with cultural taken it upon itself to retrieve it. Twen- tional organizations and institutions. norms. ty years on, the two main reasons for These collaborative efforts lead to a As the Research Program is still participation in research remain: to better understanding of the border relatively new at the clinic, with the learn about the health situation of per- community on a whole, exposing the majority of research activity happening sons living along the border, and to real situation that this population is in the last couple years, the program better evaluate and improve the ser- faced with. This research allows the still has some major developments vices of the clinic. organizations involved to undertake ahead of it. The hope is to develop a The fi rst internal MTC research more effective advocacy for the people, research working group, fi rst within was in 2005, and there have certainly especially in the global arena. These the clinic, and then among the CBO been many subsequent challenges collaborations have also lead to better community. The working group would along the way. For staff to work in the coordination between local organiza- function to develop general policies community conducting surveys and in- tions, as well as between these organi- and procedures, especially addressing terviews, there is a constant security zations and the local community. issues of ethical research. With a strong threat, as they may not have the proper As the research has begun to in- background in research work, Saw identifi cation papers. It has also taken corporate more topics revolving around Aung Than Wai understands the bene- extensive training to introduce research health impacts and community assess- fi ts of research, but also voices a strong skills and concepts to staff, and this has ment, MTC faces typical research chal- concern for ethical and psychosocial to be re-taught often in response to a lenges. Qualitative research is easier considerations when working with the high staff turnover. A lack of knowl- to understand when data and facts can vulnerable population living along the edge surrounding research, its proce- be collected, but MTC fi nds that anec- border. Even now, there is very little dures and it benefi ts among the target dotal evidence must inform data inter- research conducted inside Burma, with population are further problems. pretation. The accuracy and quality of legal, security and logistical challenges Whether research is done within the the data collected should be constantly continuing to create obstacles. With community or among staff at the clinic, challenged, especially in the context of about 50% of the clinic patients com- a general lack of understanding of the trying to understand social rather than ing from Burma, MTC staff struggle to goals and benefi ts of a research project technical measures. The more straight- understand the patient situations, health can lead to poor participation. Thus, forward areas include monitoring prev- care options, and outcomes. the information is not as informative as alence of illnesses and quality improve- is sometimes hoped. Research Coordi- ment, in which case consistent and

FROM RICE COOKER TO AUTOCLAVE | 87 either boiling or the use of reagents. Room safety and sterilization was also addressed. As this training program fi nished in the RH department, it was clear that all the departments of the clinic would benefi t from incorporat- ing a similar infection control aspect into their monitoring and evaluation program. In order to make this possible, more training was needed. An upgrade training was provided for all current medics to ensure that they received the new information, and all health care training curriculums were perma- nently changed, and to implement this, a 3 to 4 day infection prevention component was added to the monitoring and evaluation module. Working independently of each other, with some departments fi nding greater success than others; in 2006 it INFECTION PREVENTION was decided to move towards more standardized protocol. An infection UNIT prevention working group was brought together with its fi rst task being to prevention techniques such as hand evaluate the current procedures of each In the earliest stages, a rice cooker was washing and using protective barriers department. From this initial evalua- used to clean one set of instruments. such as gloves, but there was not al- tion it became apparent that external Since there were five to ten procedures a day, it took time to do so many steriliza- ways a monitoring and evaluation sys- factors were playing a major role in tions. tem within the departments to ensure medics not properly adhering to the The clinic worked for nearly two years these actions were being performed. In procedures. Therefore, the second task with one rice cooker until an autoclave 2000, the blood transfusion, HIV pre- of the working group was to focus on was donated. vention programs, and medical waste improving supplies and logistics; how Infection Prevention Unit was not disposal programs were upgraded and could a person be expected to wash offi cially established until 2008, but as Mae Sot Hospital staff came to the their hands if sinks weren’t always with so many sections of Mae Tao clinic to demonstrate appropriate tech- working properly or there wasn’t any Clinic, the activities of the Infection niques for labeling and separation of soap? Facilities were improved, and Prevention program started long before medical waste. changes were made to the management there was an offi cial title for them. For The Reproductive Health Moni- of supplies, including ordering and example, the Laboratory was the fi rst toring and Evaluation Project initiated storage, resulting in improved avail- department to formalize safety proce- in 2002 was a two year project, imple- ability of soap and other sterilization dures. Staff received training and pro- mented to improve quality of Repro- products. These improvements to sup- cedures for specialized blood with- ductive Health services. The post- ply management and logistics certainly drawal techniques, sample handling, abortion care training within this lead to enhancements in medics’ infec- and sharps disposal. The growing clin- project included an “infection control” tion prevention behaviors, but they ic required universal precaution proce- section within the monitoring and eval- were not the only infl uencing factors to dures to maintain quality of service and uation training component. The staff consider. in 1994, a universal precaution work- began using a monitoring and evalua- Another external factor infl uenc- shop was held, highlighting needle tion checklist that included such things ing adherence to infection prevention holding techniques and medical waste as: hand washing, using gloves cor- procedures was a lack of knowledge; disposal. rectly, and using barriers such as masks even though all medics were receiving All health care related trainings or gloves. This was an opportunity to training on the topic during their initial conducted by MTC over the years have ensure that infection prevention proce- health care training, it was decided that contained a universal precautions mod- dures were being followed. Training this was not enough: upgrade trainings ule, with staff learning basic infection included sterilization techniques, via were needed. In 2008 a new Infection

88 | FROM RICE COOKER TO AUTOCLAVE Prevention Unit (IPU) was established, with ongoing upgrade trainings incorporated as one of the responsibilities of the staff in this unit. An added responsibility of the IPU is the sterilization of medical equipment and the preparation of bandaging materials, such as gauze, for the clinic departments. It has also been identifi ed that external monitoring and evaluation is a necessary practice for each department, and may also lead to improved behaviors. The hope is to begin regular external evaluations, both external to the department, and external to the clinic. Before this happens though, the working group and staff of the IPU continue to work towards updating, improving, and standardizing a checklist for use throughout the clinic departments. One of the departments that the IPU works closely with is the Water and Sanitation Department. Together, PHARMACY they are currently working on improv- Originally, MTC didn’t have a tient also prescribes and explains the ing medical waste management, with cash budget to purchase medicine, and medications. The Communication and changes to handling procedures, and the Catholic Church, supported by Fa- Language Assessment Research Proj- future plans to address storage proce- ther Manat Supalak, donated medicine ect launched in 2005 provided insight dures as well. and supplies for the fi rst two years of that lead to improvements. The re- New challenges are presented in the clinic’s existence. Each week, the search revealed that patients usually relation to the broadening range of ser- staff would go to a supplier in Mae Sot understand their diagnosis, but mix up vices provided by the clinic, and by the and collect the supplies, choosing what doses of their medications. This led to wider range of illnesses treated. This was needed; items such as quinine, tet- establishment of a new system which combination increases threats and ne- racycline, paracetemol, gauze, and created medicine bags marked with cessitates continually improving tech- spirits. Visitors donated any other dosage and time of day indicated in niques. Each department appoints a medicine. From 1992 until 1997, Mé- pictorial form. Staff with additional person who looks after infection pre- decins Sans Frontières (MSF) donated language skills was also added at this vention; however, further steps need to medicines on a monthly basis, com- time to avoid language barriers. Phar- be taken to ensure new staff members prised of twenty medications on an es- macy staff members need to speak are trained, and that supplies are al- sential drug list. The MTC pharmacy various languages – the estimated ways available. Today, the ‘wish list’ also acted as the distribution center for breakdown of patient languages is 52% of the IPU is a new autoclave. The fi ve other student camps along the bor- Burmese, 34% Karen, with the remain- clinic has already outgrown the current der for a few years, until they began to der speaking other ethnic languages. autoclave, and it cannot sterilize some work directly with their donors. Whilst Further, about 20% of patients have instruments. The desire of Sandy and there has been direct donation of medi- never been to school, and only 37% of the IPU team is clear; to reduce the risk cal supplies, customs duty charges those who had attended reached grade of infection, both for the staff and pa- have hindered pharmaceutical compa- 4. tients. With the dedicated staff con- nies from making direct donations. The fi rst medical supplies and tinuing to work as they have done, it is Just as in any health care setting, medications that Mae Tao Clinic used only a matter of time before this will there is a challenge in ensuring patient to treat patients were donated from happen. understanding of their medication and sympathetic supporters in the Mae Sot treatment. After the clinic had identi- area. As the patient population grew, fi ed diffi culties with the patients’ un- and the donations no longer met the in- derstanding of both their ailments and creasing need, the clinic began pur- treatments, a protocol was established chasing medical supplies from local whereby the medic who sees the pa- markets and pharmacies. It quickly be-

FROM RICE COOKER TO AUTOCLAVE | 89 came apparent that this was not very a quarterly order. In 2008, an old the medications are of good quality, cost-effective and so, in 1998, through kitchen space was renovated, provid- and verifying that the medications are the assistance of Mae Sot Hospital, the ing an offi ce and large storage space used for the proper illness, in the prop- clinic began ordering supplies from for a new Central Pharmacy. A net- er doses. The staff of the Central Phar- medical companies in Bangkok. worked computer system was devel- macy is in a unique position because, Until 2008, all pharmacy services oped which now allows for each de- unlike the other clinic departments, were conducted out of a pharmacy at- partment to order medications from the which work relatively independent of tached to the Medical Outpatient De- Central Pharmacy on a weekly basis, each other on a day-to-day basis, the partment, with a small storeroom sup- resulting in effi cient and accurate de- pharmacy is linked to nearly every de- plying medications to the rest of the livery of supplies to each department. partment. The pharmacy staff can be clinic departments on an “as needed” This also means a more accurate in- looked to as a valuable source of medi- basis. Each department had their own ventory system and simplifi ed quarter- cation information; they are always small pharmacy area to store their in- ly supply orders to wholesalers in willing to discuss how a medication is ventory, with each department placing Bangkok. This system helps to save properly used and any precautions that money and prevent the medication should be observed. The hope for the shortages that occurred frequently in future is that more medics will utilize the past; shortages which required ex- this valuable support. pensive emergency medication pur- Naw Klo explains that plans for chases to be made from pharmacies in the future incorporate continued devel- Mae Sot. opments with the new networked computer system. As more and more in- MTC now stocks over 470 items. ventory and patient information is The medications used at the clinic stored electronically, work can be done follow the Burma Border Guidelines to cross-reference pharmacy records (BBG), a publication put together by directly to patient records, specifi cally the health organizations working along data on the medications prescribed. the Thailand-Burma border in a move This will allow for even further effi - to standardize care offered along the ciency and cost-effective work to be border. done in the Central Pharmacy. A senti- ment expressed time and time again at Much donated-in-kind medicine must be thrown away, either spoiled or expired. Mae Tao Clinic is the desire to improve; the Central Pharmacy is no ex- All of this work is coordinated by ception. Naw Klo echoes the wish to a dedicated group of medics who have continually learn and develop, “We are all been trained in pharmacy manage- always willing to learn, if others want ment. They are responsible for keep- to give us more information, [or] make ing track of inventory levels, ensuring suggestions.”

90 | FROM RICE COOKER TO AUTOCLAVE PARTNERSHIPS: 2005 - 2009

Access Program (GHAP) , the Mae Tao to this changing dynamic and increased INTERNATIONAL Clinic, the Back Pack Health Worker responsibility. Team and Mobile Clinic ethnic In 2008 a strategic planning meet- PARTNERSHIPS groups—have been able to establish a ing on migrant health was held to dis- network of 12 mobile health centers in- cuss challenges and opportunities to As mentioned in the Research side Burma that serve as capacity collaborate. This was coordinated by Chapter, MTC began to conduct more building sites for 33 maternal health the Thai Ministry of Health and result- research in recent years. International workers, 147 health workers, 350 tra- ed in a Strategy Paper. Subsequently, partners facilitating MTC staff learn- ditional birth attendants and other com- each participating organization was ing more about how to conduct re- munity participants. obliged to include the recommenda- search, and more importantly, to lever- Although the long-term objective tions in their approach. These included age the results for service improvements of the project is to reduce maternal and ensuring migrant workers’ access to and advocacy. neonatal morbidity and mortality the Thai public health system, manag- The School Health Team at Mae among IDPs within eastern Burma, the ing health insurance for migrant work- Tao Clinic collaborated with Tokyo primary aim is to increase access to ers, increasing effectiveness of com- University and other CBO partners proven antenatal interventions and to munity health volunteers, increased (BMWEC, Burmese Migrant Teachers basic emergency obstetric care. The funding, and increased collaboration. Association, SAW) on a research proj- centers provide proven and appropriate The last fi ve years were not so ect regarding school health assessment antenatal, peripartum and postpartum much characterized by new partner- and evaluation for all migrant schools newborn and maternal health interven- ships, but rather gaining important which have students grade 1-4. The tions, and are sites for standardized traction in the existing partnerships results of the baseline survey provide a collection of program indicators, as and collaborations. An important ex- basis to engage the teachers in dialogue well as referral centers for specialized ample is the Coordinating Team for the about future planning for environmen- emergency obstetrical care. Displaced Children’s Education (CT- tal health in their schools. DCE) , which was formed to intervene Maternal and Child health is an- in the current crisis of education and other area which has benefi tted from LOCAL protection for Burmese children in international research partners. The COLLABORATION September 2007. The team is com- RAISE project aims to improve cross- CONTINUES TO prised of Burmese community leaders, border reproductive health care through teachers and health workers who are the upgrading of clinics and health GROW committed to assist displaced children. worker skills inside Burma. Through MTC has been involved with CTDCE this project, facility checklists, data As noted previously, MTC was for the Emergency Dry Food Program, collection, standardization of care, established purely as a service provid- securing emergency food supplies for community assessment and the trainer. These days, MTC plays a much boarding facilities, as well as developing curriculum were upgraded. This broader role in areas such as program ing Child Protection policies and Stan- project created a more standardized management, policy development, and dards of Care for boarding facilities. training curriculum and ongoing pro- collaboration. MTC’s nascent under- This type of collaboration is very cess of improving data collection and standing of these areas has developed powerful if it can be implemented ef- health services. quickly and its partner engagement has fectively. Of course, there are many The Mobile Obstetric Maternal evolved along with this role accord- challenges ahead, but the engaged ap- Health Workers (MOM) Project em- ingly. These days, the wide scope of proach of the Thai Ministry of Health ploys a unique approach to addressing programmatic areas in which MTC’s coupled with the tenacity and dedica- the dire neonatal and maternal health partners operate is a refl ection of the tion of the community-based organiza- situation among internally displaced evolution of the clinic’s role. MTC’s tions should provide opportunity for persons (IDPs) living in eastern Bur- partnerships with the Thai Ministry of much improvement in the coming ma. In partnership —the Global Health Health and other stakeholders testifi es years.

FROM RICE COOKER TO AUTOCLAVE | 91 DR. CYNTHIA’S THOUGHTS: LOOKING TO THE FUTURE

With every year, it seems that the border population’s needs grow in scale and complexity. While MTC was founded to manage referrals and minor medical problems, the MTC of the future must prepare to face complex cross border public health, social and medical issues. Drug resistant tuberculosis along the border, for example, poses a large public health challenge which MTC cannot solve alone. The increasing population along the border creates education and social issues which cannot be solved in isolation.

MTC is looking to the future with a view to stronger partnerships with local and international organizations. MTC will continue to train and groom medical professionals to increase the expertise in the community. The umbrella of social services which address psychosocial and education issues continues to expand. MTC also looks to the future of the community. In the past, ethnic groups inside Burma had strong civil societies which fostered support for health, education and social support. This has been dismantled by militarization. It was not through active ﬁ ghting that this occurred – it was through the systematic control of resources such as land. Forced relocations, loss of livelihood opportunity, and military conscription are among the tools which have led to communities separated and without identity. The way forward will require education, social change, and collaboration between community groups and CBOs. If civil society and community is strengthened in the border area, this will provide the ability to rebuild civil society inside Burma when it is ﬁ nally possible. Everyone should raise their voices. Not just politicians, but women, children, workers, and every individual. Finally, the younger generation is our future leadership. Some might think that the legacy of Mae Tao Clinic will be hundreds of thousands of patients treated and comforted. Mae Tao Clinic hopes that our legacy will be a stronger civil society, and a generation of young leaders who have been trained, encouraged and groomed to lead.

Dr. Cynthia Maung

92 | FROM RICE COOKER TO AUTOCLAVE DONORS

To every donor over our 20 year history: Thank you! To the travelers stumbling upon the clinic in Mae Sot and donating some used clothing, to those who have never visited the clinic yet raise money at home in their communities, those who have donated online, donated medicine in-kind, volunteered their time, or spread the word about the plight of the Burmese through advocacy: Thank you. We wish to thank all of the individuals, organizations, and companies who have donated much-needed supplies in-kind over the years. This includes blankets, medicine, medical equipment, building supplies, food, school supplies and books, clothing, and toys among other things. We wish we could mention every individual, every baht donated, and every effort made on our behalf since it has made the work of the clinic possible over 20 years. Over the years, regrettably this is not possible -- please accept the writing of this book as tribute to your efforts and support.

• Action Medeor (Germany) America (USA) ect (USA) • Actions Birmanie • Burma People’s Relief Group • Consortium Thailand • Aide Medicale International • Burma Refugee Project Los Ange- • CUSO/VSO/Pure and Co (Cana- (France) les (USA) da) • Alice Harding • Burma Relief Centre (Japan) • Daniel Wood • American Jewish World Service • Burma Relief Centre (Thailand) • David O Kingston Foundation (USA) • Burma Relief Centre (USA) (USA) • Anthony Parisi (USA) • Burma Volunteer Project (Thai- • Daw Suu Foundation (UK) • Avaaz land) • Denish Church Aid (Denmark) • Australian People for Health Edu- • Burma Youth Volunteer Associa- • Department for International De- cation and Development Abroad tion (Japan) velopment (UK-DFID) (APHEDA - Australia) • Burmese in Australia Water Festi- • Dietel Partners • Australia Burma Friendship Asso- val Committee (Australia) • Dietrich Botstiber Foundation ciation (Australia) • Burmese Migrant Workers Educa- (USA) • Australian Baptist World Aid tion Committee (Thailand) • DI-FAEM German Medical Insti- • Australian Volunteer International • Burmese Refugee Care Project tute (Australia) (USA) • Direct Relief International (USA) • Bang-On and Prachaya Siriprusan- • Burmese Refugee Project • Doctors of the World (USA) an, and Andrew and Oranood Cow- • Canadian Embassy • DOEN Foundation ell (Thailand) • Carsten Hartmann • Dr. Tay • BeCause Foundation (USA) • Cathleen and David Yost (USA) • Education Sin Fronteras (Spain) • Bienvenido Tan • Catriona Walsh (Ireland) • Euro Burma Ofﬁ ce • Bill and Jean Lane (USA) • Chiang Mai University (Thailand) • European Committee / WEAVE • BK Kee Foundation (USA) • Chien Shang-Lien • Family Health International • BMTT and TBTCC • Child’s Dream (Thailand) (USA) • Body Shop (UK) • Children on the Edge (UK) • Mr. Fang Ching-Jung Frank • Books Abroad (UK) • Children’s World (UK) • Father Manat Supalak • Brackett Foundation (USA) • Chou-Ta Kuan Foundation (Tai- • The Flora Family Foundation • British Consul wan) (USA) • British Embassy • Christopher Wu • Foundation of Human Rights in Ja- • Buncheon Migrant Workers House • Christ Church (Thailand) pan • Burma Border Projects (USA) • Clear Path International (USA) • Foundation for The People of Bur- • Burma Campaign (Spain) • Clinton Foundation (USA) ma (USA) • Burma Children’s Fund • Canadian International Develop- • Friends of MTC in Taiwan (Tai- • Burma Fund ment Agency (Canada) wan) • Burma Medical Association North • Columbia University, RAISE Proj- • General Direction for Develop- ment, Cooperation and Humanitar- FROM RICE COOKER TO AUTOCLAVE | 93 ian Action • Maltesers International (Germany/ • Scott and Tiffany McDonald • Global Health Access Program Thailand) (USA) (USA) • Mariposa Foundation (USA) • Seo So Moon Church (Korea) • Global Health Conference (USA) • Matriona (France) • Seongdong Migrant Workers Com- • Global Health Council (USA) • Medical Aid for Children (Korea) mittee • GreaterGood.org (USA) • Medical Mercy Canada (Canada) • Shanti Volunteer Organisation (Ja- • HelpAge International • Médecins Sans Frontières (France) pan) • Help Without Frontiers (Italy) • Mei Li Kwan-Gett • Shining Charity Foundation • HMK Organisation • Middlesex School • SK Dream Japan • Ida Monzon • Miao Jan (Malaysia) • SK Foundation • Interchurch Organisation for De- • Mitwelt-Netzwerk (Inge Sterke- • Stephanie Lazar velopment Co-operation (ICCO - Germany) • Shannon and Sebastien Sirois Netherlands) • MOM Project (BMA/GHAP) (Canada) • International Health Partners • National Endowment for Democ- • SOLCO (Denmark) • International Center for Huma racy (USA) • Stichting Vluchteling (Nether- Rights and Democratic Develop- • Network for Good (USA) lands) ment • New York Trust Foundation • Susie Costello (Australia) • International Committee of the (USA) • Swiss Rotary Red Cross (Switzerland) • New Zealand Embassy • The Supreme Master Ching Hai • International Rescue Committee • Nonna Gabriella (Italy) International Association (Taiwan) (USA) • Norwegian Church Aid (Norway) • Taipei Overseas Peace Services • International Rescue Committee • Norwegian Embassy (Taiwan) (Thailand) • Not on Our Watch (USA) • Taiwan Foundation for Democracy • International Support Group (Thai- • Open Society Institute (USA) (Taiwan) land) • Operation Smile (USA) • Tan Geok Hwa • Interpares (Canada) • Operation USA • Terre Des Hommes (Netherlands) • Japan Association for Mae Tao • Otalgeville District Secondary • Thailand Burma Border Consor- Clinic School tium (Thailand) • Japanese Burma Community (Ja- • Path Canada • Thavibu Gallery (Thailand) pan) • Paula Bock and Tao Kwan-Gett • Two Elephant Factory (Thailand) • John Hopkins University (USA) (USA) • UNFPA • John Hussmann Foundation (Thai- • People’s Forum on Burma • UNICEF land) • Philip Lowry • Union Aid New Zealand • John P Hussmannn (USA) • Perinatal HIV Prevention Trial • United Nations Women’s Guild • Jubilee Action Aid (UK) (Thailand) • Unitarian Universalist Service • Julian David Pieniazek (UK) • Peter Moore Foundation Committee (USA) • Jun Kobayashi (Japan) • Pﬁ zer Global Health Programme • University of California San Diego • Just Aid Foundation (Canada) (USA) (USA) • Kapi’olani Child Protection Center • Planet Care (USA) • University of California San Fran- (USA) • Primate World Relief Development cisco (USA) • Karen Aid (UK) Fund (Canada) • University of Washington (USA) • Karen Baker • Project Umbrella (Dr. David & • USAID (USA) • Karen Development and Relief Cathy Downham – Canada) • Walden Asset Management / Ann Foundation (UK) • Ramon Magsaysay Award Founda- Spanel • Karen Foundation Aid (UK) tion (Philippines) • Washington University (USA) • Karen Refugee Camp Women’s • REMEDY • Wisdom in Action (USA) Development Group (Scotland) • Rotary Canada • Women’s Commission for Refugee • Kedron State High School • Rotary Club Eastern Seaboard Women and Children (USA) • Kurt & Cathy Bradner (Thailand) • Women’s Education for Advance- • Larry Mueller (USA) • Roth Family Foundation (USA) ment and Empowerment (WEAVE • Leo and Family (Australia) • Sacramento Friends of MTC – Thailand) • Lonely Planet (Australia) (USA) • World’s Children’s Prize for the • Mary Knoll • Safe Abortion Action Fund (UK) Rights of the Child (Sweden) • Mae Sot Hospital (Thailand) • Sandoz (Italy) • Yam Fow Phaen Din Foundation • Mahidhol University (Thailand) • Sa Sa Ka Wa Foundation (Japan) • Young Green Foundation (USA)

94 | FROM RICE COOKER TO AUTOCLAVE AWARDS

1999 JONATHAN MANN HEALTH AND HUMAN RIGHTS AWARD (USA)

In 1999 Dr. Cynthia was unable to attend the award ceremony in Washing- ton, D.C., so Jimmy Carter presented the award via video conference to Bang- kok. Dr. Cynthia’s acceptance speech was broadcast via satellite to Washington, London, India, and Ghana. Jonathan Mann died an untimely death in September 1998, but he and Dr. Cynthia would have a lot to discuss if they could have met. He brought the world’s attention to the basic notion that improved health cannot be achieved without basic human rights, and that these rights are meaningless without adequate health. Dr. Cynthia works daily towards this ideal.

1999 JOHN HUMPHREY FREEDOM AWARD (CANADA)

Dr. Cynthia Maung and prisoner of conscience, Min Ko Naing, were jointly awarded the 1999 John Humphrey Freedom Award of the Interna- tional Centre for Human Rights and Democratic Development, for their efforts to empower the people of Burma. “Dr. Cynthia Maung and Min Ko Naing inspire all those who struggle for peace and justice in Burma,” said Warren Allmand, President of the International Centre, upon announcing the decision of the international jury. “We hope that this Award will help provide some measure of protection to Dr. Cynthia Maung and Min Ko Naing and further expose the brutal dictatorship in Burma,” explained David Matas, a Winnipeg lawyer, who chaired the meeting of the international jury held to consider over 50 nominations from around the world.

1999 AMERICAN WOMEN’S MEDICAL ASSOCIATION PRESIDENT’S AWARD (USA)

2001 FOUNDATION FOR HUMAN RIGHTS IN ASIA SPECIAL AWARD (JAPAN)

The purpose of the Foundation for Human Rights in Asia (FHRA) is to contribute to the improvement and development of the human rights situations in Asia. As part of these activities, the Foundation established the Awards to present to individuals and groups who have conducted mer- itorious services toward improving or solving the human rights situations in Asia. The Women Human Rights Special Award is given to organizations or individuals who have contributed particularly to the human rights of women. FROM RICE COOKER TO AUTOCLAVE | 95 2001 VAN HUEVEN GOEDHART AWARD (NETHERLANDS)

The Van Hueven Goedhart Award is given every second year by Stichting Vluchteling Netherlands Refugee Foundation to a refugee or an internally displaced person or a person who is closely involved in a refugee community.

2002 RAMON MAGSAYSAY AWARD FOR COMMUNITY LEADERSHIP ( PHILLIPINES)

The RMAF recognizes and honors individuals and organizations in Asia regardless of race, creed, sex, or nationality, who have achieved distinction in their respective ﬁ elds and have helped others generously without anticipating public recognition. The Com- munity Leadership award recognizes leadership of a community toward helping the disadvantaged have fuller opportunities and a better life. In electing Cynthia Maung to receive the 2002 Ramon Magsaysay Award for Community Leadership, the board of trustees recognized her humane and fearless response to the urgent medical needs of thousands of refugees and displaced persons along the Thailand-Burma border.

2003 ASIAN HERO AWARD

Dr. Cynthia Maung was included in Time Magazine’s November article on 18 Global Health Heroes. http://www.time.com/time/magazine/0,9263,7601051107,00.html]

2005 1,000 WOMEN NOBEL PEACE PRIZE NOMINATION (GLOBAL)

Dr. Cynthia Maung was included 1,000 women from more than 150 countries who were jointly nominated for the Nobel Peace Prize. The number 1,000 is symbolic, as the 1,000 women nominated represent innumerable women worldwide who are engaged in the cause of peace and human dignity.

96 | FROM RICE COOKER TO AUTOCLAVE 2005 UNSUNG HEROES OF COMPASSION AWARD (USA)

The Dalai Lama and Wisdom in Action. “These individuals have been selected as representatives of the tens of thousands of people worldwide who quietly serve the disen- franchised and work to improve our communities thorugh their personal efforts,” says Dick Grace, board chair of Wisdom in Action, “We don’t see themor hear about them in the daily news, but they exemplify a humanism and heroism to which we must each aspire”. Wisdom in Action (WIA) is a non- proﬁ t organization dedicated to increasing awareness of the importance of compassion in action.

2005 THE EIGHTH GLOBAL CONCERN FOR HUMAN LIFE AWARD

Chou-Ta Kuan Foundation, Taiwan

2005 MITWELT-NETZWERK AWARD (GERMANY)

2005 VOICE OF COURAGE AWARD

The Women’s Commission honored Sophia, a refugee from Burma, for her work as program manager of the reproductive health inpatient department at the Mae Tao Clinic on the Thai-Burma border. At the clinic, Sophia trains traditional birth attendants, maternal child health trainees and other reproductive health staff.

FROM RICE COOKER TO AUTOCLAVE | 97 2007 SHINING WORLD LEADERSHIP AWARD

Presented by The Supreme Mas- ter Ching Hai International Association January 12, 2007

2007 ASIA DEMOCRACY AND HUMAN RIGHTS AWARD (TAIWAN)

The Taiwan Foundation for Democracy awarded its Asia Democ- racy and Human Rights Award in 2007 to Dr. Cynthia. Legislative Speaker Wang Jin-pyng who is also chairman of the foundation explained, “Dr. Cynthia is going beyond her mandate as a physician by turning a refugee population into a community based on shared values and respect for human rights, as well as by linking her cause to the international community”. Hsaio Hsin-huang, the foundations’ standing supervisor further explained, “Giving the award to her means we have formed a broader deﬁ nition of democracy and human rights… from re- porters to doctors, everyone can ﬁ ght for human rights.”

2007 WORLD’S CHILDREN’S PRIZE FOR THE RIGHTS OF THE CHILD (WCPRC) HONORARY AWARD (SWEDEN), CHILDREN’S WORLD ASSOCIATION

WCPRC has grown to become the world’s largest annual education and empowerment process for the rights of the child, democracy and global friendship for children. As part of this process, the children award their prized for outstanding contributions to the rights of the child.

2008 CATALONIA INTERNATIONAL PRIZE (SPAIN)

Jointly awarded with Daw Aung San Suu Kyi for their selfl ess sacrifi ce in promoting pro-democracy activities, freedom, and human rights in Burma. “This is the fi rst time the award has gone to Burmese ladies. The prize committee selected them for their sacrifi ces and devo- tion to the freedom of Burma, democratic struggle and social work,” said Ms. Teresa Salar, assistant secretary of the prize selection committee. The award is presented annually to persons who have made remarkable contribution to the development of cultural, scientifi c or human rights anywhere in the world.

98 | FROM RICE COOKER TO AUTOCLAVE 2008 “THAN KHUN PHAN DIN” AWARD (THAILAND)

2009 PEOPLE WHO INSPIRATION AWARD (THAILAND)

International trip to Bercelona, Spain.

FROM RICE COOKER TO AUTOCLAVE | 99 RESOURCES ORGANISATION WEB SITES:

Assistance Association for Political Prisoners (Burma) Lahu Women’s Organisation http://www.aappb.org/ http://www.womenofburma.org/lwo.htm

Backpack Health Worker Team (BPHWT) Mae Tao Clinic http://www.backpackteam.org/ www.maetaoclinic.org

The Brackett Foundation Migrant Assistance Program http://www.brackettfoundation.com/ http://www.mapfoundationcm.org/

Burma Children Medical Fund (BCMF) National Health and Education Committee http://www.burmachildren.com/ http://www.nhecburma.org/

Burma Labour Solidarity Organisation Palaung Women’s Organisation http://www.burmasolidarity.org/ http://palaungwomen.org/

Burma Medical Association (BMA) Partners Relief & Development http://www.bmahealth.org/ http://partnersworld.org/

Burmese Lawyers’ Council Shan Women’s Action Network http://www.blc-burma.org/ http://www.shanwomen.org/

Burmese Migrant Workers Education Committee (BMWEC) Social Action for Women http://www.bmwec.org/ http://www.sawburma.org/

Burmese Women’s Union Thailand Burma Border Consortium http://www.burmesewomenunion.org/ http://www.tbbc.org/

Clear Path International USAID http://www.cpi.org/index.php http://www.usaid.gov/locations/asia/countries/burma/index.html

Free Burma Rangers Women’s Education for Advancement and Empowerment http://www.freeburmarangers.org/ http://www.weave-women.org/

Global Health and Access Program Women’s League of Burma http://www.ghap.org/ http://www.womenofburma.org/

Human Rights Education Institute of Burma Yaung Chi Oo Workers Association http://www.hreib.com/ http://yaungchioo.org/

Kachin Women’s Organisation Thailand News & Information: http://www.womenofburma.org/kwat.htm Burma Library Online Karen Aid http://www.burmalibrary.org/ http://www.karenaid.org.uk/ CIA Factbook Burma Karen Human Rights Group https://www.cia.gov/library/publications/the-world-factbook/ http://www.khrg.org/ geos/bm.html

Karen Teacher Working Group Democratic Voice of Burma http://www.ktwg.org/ http://english.dvb.no/

Karen Women’s Organisation Irrawaddy News Magazine http://www.karenwomen.org/ http://www.irrawaddy.org/

Karen Youth Organisation Mizzima News http://karenyouthktl.org/ http ://www.mizzima.com/ 100 | FROM RICE COOKER TO AUTOCLAVE ARTICLES: VIDEO

“For Choo, it’s all work and no play” – Bangkok Post article on BBP psychologist Elizabeth Call’s discusses her impression of the December 20, 2009 Dr. Cynthia Maung and the conversation that led to the creation of http://www.bangkokpost.com/news/investigation/29651/for-choo- Burma Border Projects. it-all-work-and-no-play http://www.youtube.com/watch?v=-9ZJfTAIXo0

“Saving Lives on the Burmese Border”, BBC Article from March VOAvideo report, “Refugee Doctor Treats Burmese Victims” 2007 http://www.youtube.com/watch?v=HtupmwRi8d0 http://news.bbc.co.uk/2/hi/asia-paciﬁ c/6418645.stm The First Lady Laura Bush visited the Burmese refugees camp and “In Pictures: Border Healthcare” – BBC photo report from March the Mae Tao Clinic, where she met thousands of refugees and Dr. 2007 Cynthia Maung. 2008 http://news.bbc.co.uk/2/hi/in_pictures/6419435.stm http://www.youtube.com/watch?v=TTACB_tVDJM

Burma Journal: The Hard Work of Healing a Bitter Pill for Doc- Trailer for the documentary ﬁ lm, “Crossing Midnight.” Directed tors. November 2009. by Kim A. Snyder for the BeCause Foundation, 2009. http://www.politicsdaily.com/2009/11/21/burma-journal-the-hard- http://www.youtube.com/watch?v=-f63-n0RRos work-of-healing-is-a-bitter-pill-for-doc/ Today show article about Mae Tao Clinic, 2009 “Burmese Patients Continue to Flock to Mae Tao Clinic” Indepen- http://today.msnbc.msn.com/id/26184891/#30577978 dent Mon News Agency, November 2009. http://www.monnews-imna.com/newsupdate.php?ID=1590 Time Asia Heroes Proﬁ le, 2003 http://www.time.com/time/asia/2003/heroes/cynthia_maung.html “Dr. Cynthia Maung: Healer of Broken Souls” Time Magazine, 2003. http://www.time.com/time/asia/2003/heroes/cynthia_maung.html

“A Land of War: Journey of the Heart”, Seattle Times. http://seattletimes.nwsource.com/special/burma/

“A Clinic Where One Doctor Dispenses Hope” The Ottawa Citi- zen, 2006. http://www.canada.com/ottawacitizen/news/story. html?id=09187c19-86f0-4c68-92eb-bdd0028055c2

FROM RICE COOKER TO AUTOCLAVE | 101 BOOK CONTRIBUTORS WRITING

Paula Bock Tom Buckley Atsuko Fitzgerald Gary Hallemeier Michelle Katics Jolene Lansdowne Jacqui Whelan Tao Kwan-Gett Naing Min

EDITING / FACT CHECKING

Aung Than Wai Paula Bock Shaun Butta Lisa Houston Michelle Katics Dr. Cynthia Maung Kathleen O’Flynn Dr. Terry Smith Thar Win

INTERPRETER

Eh Mwee Mae Soe Maung Maung Tinn

PHOTOS

Nathalie Dusseaux Richard Humphries Michelle Katics MTC staff Olivier Ouadah Tom Reese

GRAPHIC & LAYOUT

Saw Lin Kyaw

A warm thanks to all who were inter- viewed, and provided historical information about the clinic who were not mentioned here.

102 | FROM RICE COOKER TO AUTOCLAVE Index

A E

Adolescent Reproductive Health Network 77 Emergency Dry Food Program 91 Ah Zin Village 34 Ethnic Health Organization 34 American Women’s Medical Association President’s Award 95 F Asia Democracy and Human Rights Award 98 Asian Hero Award 96 Father Manat Supalak 35, 93 autoclave 88 fi re-pit burns 17 fi rst annual report 55 B Foundation for Human Rights in Asia 95 Back Pack Health Worker Team 23, 91 G Bamboo Children’s Home 4, 44 blood transfusion program 35 Gay Moo 75 Bo-im, Dr. (from Korea) 76 Global Health Access Program (GHAP) 34, 91 Burma Children Medical Fund (BCMF) 78 Burmese Migrant Workers Education Committee 42, 77 H Burmese Relief Center 55 Health Information Systems 56 Burmese Women’s Union 77 HIV/AIDS 3 C HIV rapid tests 28 Hla Thein 52 Catalonia International Prize 98 Hsa K’Paw 29 Catholic Church organizations 35 Human Rights Education Institute of Burma (HREIB) 78 Chiang Mai Hospital 78, 79 Child’s Dream 79 I Child Protection policies 91 IDP camps 9 clinic administrator 56 internally displaced persons (IDP) 9, 22 Committee for the Protection and Promotion of Child Rights (CP- PCR) 44, 77 J Coordination Team for Displaced Children’s Education (CTDCE) 43, 91 Johnathan Mann Health and Human Rights Award 95 Cyclone Nargis 4 John Humphrey Freedom Award 95 Johns Hopkins Center for Public Health and Human Rights 34 D Johns Hopkins University 59 delivery certifi cate 44 K donations in-kind 93 Dr. Kanoknart Pisuttakoon 35 Karen National Union 9 Dr. Kyaw Zayar 75 Karenni Nationalities Health Worker Organization 59 Dr. Shee Sho 52 Karen Women’s Organisation (KWO) 52, 77 Dr. Singh 34 Kway Kaloke refugee camp 44 Kyaik Dom 34

FROM RICE COOKER TO AUTOCLAVE | 103 L S

Lawkwa (dental medic) 75 Saffron Revolution 4 Saw Law Kwa 16 M Saw Than Lwin 86 Mae Sot Hospital 17, 35, 78 Sein Han 22 malaria 29 Shan Health Committee 59 malnutrition 3 Shining World Leadership Award 98 Manerplaw 9 Social Action for Women (SAW) 77, 78, 86 Maternal and Child Health Booklet 44 staff retention 54 Médecins Sans Frontières 55 statelessness 77 Migrant Assistance Program (MAP) 85 State Peace and Development Council (SPDC) 9 migrant health coordinator 56 Student camps 9 Migrant workers 10 T Mobile Medical Teams 22 Mobile Obstetric Maternal Health Workers (MOM) Project 91 Terre Des Hommes (TDH) 55 Thai Birth Registration Certiﬁ cates 44 N Thai Ministry of Education 42, 77 National Access to Antiretroviral Program for People Living with Thai Ministry of Health 35, 44, 59, 91 HIV/AIDS – Extension (NAPHA) 36 The Eigth Global Concern for Human Life Award 97 Naw Htoo 4, 44 Thornton, Kanchana 78 Naw Ree 33 Tokyo University 91 Nay Htoo 23 Traditional Birth Attendants 58 Nightingale Health Journal 35 Trauma Care Foundation 16 NLD Women 77 Travis, Dr. Michael 76 Nobel Peace Prize Nomination 96 tuberculosis 54 P U

Palaung Women’s Organisation 77 Umpiem refugee camp 44 pediatrics department 4 Unsung Heroes of Compassion Award 97 peer counselors 70 V Plasmodium falciparum 59 Prevention of Mother to Child Transmission (PMTCT) 29 vaccination program 51 Van Hueven Goedhard Award 96 R Voice of Courage Award 97 RAISE project 91 Voluntary Counseling and Testing Program (VCT) 29 Ramon Magsaysay Award for Community Leadership 96 W Refugee camps 9 reproductive health department 3 Women’s Commission 97 Women’s Commission for Refugee Women and Children 56 World’s Children’s Prize for the Rights of the Child Honorary Award 98

104 | FROM RICE COOKER TO AUTOCLAVE