Living Ghosts
The spiraling repression of the Karenni population by the Burmese military junta
Chapter 4: Health
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Chapter Overview
Many people die from preventable or easily treatable diseases in Karenni State. Basic health services are virtually non-existent due to a lack of state funding and instability within Karenni State. Clinics lack the very basic equipment and medicine. Health Workers either have receive severely inadequate or none at all, and are severely restricted in their access to the population. These factors, compounded with harsh environmental conditions and a lack of health awareness and education people have led to a health crisis. There is a widespread need for more health services in Karenni State and health workers need unrestricted access to all parts of the population. Additionally, people need access to clean drinking water, appropriate sanitation and education about basic health care, including disease prevention.
In this chapter:
State Spending on Health
Common Diseases
Health Services
Medicines
Health Workers
Health and Sanitation
Public Health Education
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4.1 State Spending on Health
Only 2.2 per cent of Burma’s Gross Domestic Product (GDP) is spent on health care.33 The State Peace and Development Council spends less than one US dollar per person on health care each year (US $0.60).34 In comparison Cambodia spends US $6.1 per person on health care, and health expenditure represents 6.7 per cent of their GDP. Thailand and Laos spend 3.5 per cent and 3.9 per cent of their GDPs respectively, which represents a spending of US $57 and US $3.4 per person each year on health care.35 Sudan spends 4.1 per of their GDP on health care, which amounts to US $8.7 per capita.36 Health care in the USA represents 15.4 per cent of their GDP and US $2724.7 per person.37
While these figures reflect national expenditure on health care, they do not reflect health care expenditure in ethnic regions where these areas receive very little, if any, public funding for health care. In 2004 over 99 per cent of expenditure on health services in Burma came out of the patients own pockets.38
4.2 Common Disease
Most common diseases in Karenni State can be easily prevented and treated. The serious lack of awareness among the general public and health care workers, in addition to severely inadequate health care resources, results in a disproportional high number of health conditions and fatalities to disease that could otherwise be easily treated.
Over 2,000 villagers in Karenni State were surveyed with regards to their health situation, in 2003. All people surveyed had been ill in the past year. The table below outlines diseases people suffered and how common they were among the surveyed population.
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Disease
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Per cent of population afflicted
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Pneumonia
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9.22 per cent
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Tonsillitis
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7.71 per cent
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Urinary Tract Infection
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7.3 per cent
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Malaria
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6.73 per cent
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Dysentery
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5.22 per cent
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Beriberi
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3.9 per cent
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Skin Diseases
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3.56 per cent
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Diarrhea
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1.4 per cent
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Other (bronchitis, gastritis, worms, vitamin deficience, colds, hypertension, anemia, etc.)
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54.9 per cent
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The Back Pack Health Worker Team, a CBO working cross-border from Thailand that provides health care to communities in eastern Burma, conducted a similar survey and had similar results. Their survey also found that one in five children, (20 per cent), die before their fifth birthday, with 80 per cent of these deaths were caused by diarrhea, malaria and acute respiratory infections. In Burma 10.4 per cent of children die before their fifth birthday.39 By comparison, in the USA the under-5 child mortality rate is 0.8 per cent.40 Whilst Burma’s national statistic is very high and needs urgent attention, the fact remains that children in ethnic areas are twice as likely to die before their fifth birthday. There is also a high risk of maternal death for mothers with one in 12 women dying (maternal death relates to deaths shortly before, during or just after child birth).41 Most of these deaths could be prevented if women and children could access basic medical care.
“During January and
February 2007 many villages in Karenni State suffered severe
diahoerra, which led to the deaths of many people, including
children. In Tx Kxx Sxxx village two children under the age
of 15 died from diahorrea and in Jx Lx Kxxx village one child,
who was not yet one, died. In Yxxx Sxx Pxx village six people
got diahorrea and two of them died, in Hx Hxx Kxxx village
three people got diahorrea and one died,” T--- R-- said.
Food shortages and malnutrition add to the health care crises. Many villagers, including pregnant women and children, have sub-standard diets (in terms of nutritional value of food eaten and frequency). Malnutrition is rife. Across Burma over 40 per cent of children under-5 have stunted growth and nearly 30 per cent are underweight.42 These figures are higher in ethnic areas such as Karenni State. In some villages where moderate and severe malnutrition is widespreadand other support. There is also the need for greater awareness among villagers and other support. There is also the need for greater awareness among villagersthere is a need for community intervention in the form of feeding programmes of dietary requirements.
4.3 Health Services
Within Karenni State the population can be split into three groups: rural (villagers), urban (people that live in towns) and semi-urban populations (people who live between villages and towns). Living standards and access to health care differ dramatically between Urban and Rural areas and yet health services provided in towns is still drastically inadequate.
Despite their efforts, clinics, hospitals and health services that the State, NGOs or religious groups support simply do not have enough resources to provide adequate health care for the Karenni population. Additionally, many villages and surrounding areas do not have a basic clinic. Villagers who have no access what so ever to health services must travel for days over rugged terrain to access medical treatment.
“A free clinic supported by MSF-Switzerland
is located in Nxxx Lx Bxx Sxxxx village, north of Loikaw,
the capital of Karenni State. Although there is a free clinic,
it lacks the resources to treat medical emergencies. Consequently,
patients with emergencies are sent to the public hospital
in Loikaw. In such situations, the free clinic pays for only
one-third of the medical cost and the patients have to make
up the difference. As many patients cannot pay, the hospital
staff do not provide them with care. “ – N--- R-- said.
4.4 Medicines
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Among 81 villages surveyed in 2006 and 2007 only four had any clinics or health care services. One of the four clinics did not have any medicine or health workers. That represents less than five per cent of villages having any level of health care services on a permanent basis – BI Field staff 3 and 7
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There is a lack of vital medication in Karenni State. Hospitals and medical clinics that are operated by state, local and international NGO’s are allegedly suppose to provide free or affordable medicine; however this is far from the case. Hospitals and clinics do not receive any medical supplies from the SPDC and supplies that come from alternative sources are often pilfered by private chemists, with supply shelves in clinics and hospitals remaining empty. BI Field Staff reported seeing medicine from the UNICEF, with UNICEF labels, that were proclaimed to be free, being sold in private drug stores in Karenni State.
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Patients or family and friends must visit private pharmacies upon receiving their prescription from a doctor or health worker to purchase medicine and then return to either the hospital or clinic where it is then administered.
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Further exacerbating the shortage of medicine in Karenni State are the restrictions imposed by the Burmese regime, in particular, prohibiting medicines being transported to areas outside the SPDC’s control. Health workers take great risk carrying medication on their persons, and face possible imprisonment, torture and execution if discovered by the Burmese army. Consequently, health workers that do carry medicines often charge patients very high prices as compensation for the risk they take - often making them unaffordable for the majority of the population.
Additionally, if a villager does receive medicine from a health worker the treatment is often split between a number of patients, in order to maximize profits. Consequently no one receives the full course of medication and making the treatmentit ineffective.
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Traditional Medicine
In areas where people cannot access medical treatment many villagers use traditional medicine. Sometimes traditional remedies work, however, they are often inadequate. In many cases people with knowledge of traditional medicine are the only ones who can offer any relief to villagers who are in pain or ill. Knowledge about traditional medicine is passed down from one generation to the next orally. However some do not want to share their knowledge and it is being lost.
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4.5 Health Workers
Health workers face formidable obstacles and challenges in providing adequate health care to the public.
4.5.1 Shortage of Health Workers
“In one village tract
in Karenni State 18 villages are dependent on one nurse to
provide health care for all the people,” – D- W----- said.
Per 1000 people in Burma, there are 0.36 doctors, 0.2 nurses, 0.79 midwives, 0.0 pharmacists (there are only 127 pharmacists in the country), 0.99 community health workers and 0.04 other health workers.43 Burma’s health worker numbers are similar to those of Thailand, Cambodia and Sudan; however, they are very different from those of western countries. In the USA for every 1000 people there are 2.56 doctors, 9.37 nurses, 1.63 midwives, 0.88 pharmacists and 14.52 other health workers.44 In total, for every 1000 people in Burma there are only 2.38 health workers, whereas in the USA they have 28.96 health workers for every 1000 people45 – that is over 12 times the number of health workers servicing the same number of people. The situation in Karenni State is more severe. Many villages and surrounding areas have no health workers at all. The few health workers that are working in Karenni State are often ill trained, if at all trained, and lack adequate resources.
Pxx Pxxx Village Tract
Due to its rugged location, the region has neither clinics nor health workers. As villagers cannot afford to get treatment from hospitals when they are sick, some people have died from minor diseases.
Sxxx Lxx Village Tract
Sxxx Lxx village tract has neither clinics nor health workers. Patients have to be carried to Bxxx Lx Kxx hospital by the people when their health condition gets serious. Patients have died on the way.
DxxxxTx Mx Gxx, Kxxx Lxxx and Dxxx Px Village Tract
Other than DxxxxTx Mx Gxx village, there are no clinics in the villages in this village tract. There are also no trained medical staff. In some villages there are some missionary health workers, midwives and some village health workers. Patients have to pay for their own medicines.
Kxx Lxxx Village Tract
In Kxx Lxxx village tract there is only one clinic at Kxx Lxxx village but there are hardly any medicines available. Though there are some midwives and mother-and-child care workers. Villagers have to pay for all medicines.
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Some relocation sites have medical clinics, but no permanent health workers are assigned to these clinics. When villagers need health care, the SPDC will arrange health workers to come to the clinic. These health workers do not receive any salary from the SPDC. The villagers are required to pay for the cost of medicine and the travel costs for the health care workers to come to the clinics. These health workers sometimes do not bring medicine to the clinic despite being specifically called to treat people.
4.5.2 Salaries
The salaries of health workers employed by the state are inadequate. The issues that arise from this are that health workers often have to take second jobs, end up selling medicine on the black market or charge extra for medical services. The resulting crises means that clinics are often understaffed or closed, lack medicine and also drives up the cost of health services making health care unaffordable for most people. Salaries for health workers need to be increased.
4.5.3 Training
There is a lack of qualified health workers in Burma, especially in ethnic minority areas such as Karenni State. In order to fill shortages, unqualified people are hired who lack the necessary skills to diagnose and treat diseases and injuries effectively. This can lead to misdiagnosis causing permanent injury, disability, and on occasion leading to death.
In semi-urban and rural areas, self-employed nurses travel from village to village offering medical treatment in exchange for payment, either money or goods. These nurses rarely receive any medical education and they often engage in very unsafe practices, such as reusing hypodermic needles which increase the level for infection and can transfer HIV/AIDS.
Moreover many medics from Thailand that work cross border also have limited training. Some organisations that focus on cross border health care provide a two-year training course for medics, while others receive only a few months. There is a desire to improve trainings and services for health workers however, significant demands for assistance means that they do not have extended periods of time to upgrade their skills.
While some health care workers have attended short-term training, others have received no training. One health care worker admitted that he had limited knowledge and was ill trained to treat people effectively. Encouragingly however these health workers said they would be willing to participate in health-related workshops to upgrade their knowledge.
4.6 Health and Sanitation
Poor living standards result in poor health conditions and when combined with a perpetual lack of adequate health care, can lead to a health crisis. The systematic violation of human rights in Karenni State due to the armed conflict between the various fighting fractions and the Burmese military undermines the peoples’ ability and capacity to sustain their livelihoods, or improve their living conditions.
4.6.1 Water
People do not always have access to clean drinking water. In Karenni State there are not many rivers and villages are not always located along a permanent water source. To have a permanent water supply some villagers build dams to store water. These dams are their only supply of water and villagers use this water to bath, clean cooking utensils as well as for drinking. Animals also use this water for bathing and drinking and contaminate the water with their excretions. The multiple use of one water supply leads to serious contamination and potentially has severe health repercussions.
These dams are also not large enough and most people face water shortages during the summer. In some cases villagers have to walk 45 minutes each way to collect water in the midst of a civil war zone which also has other threats, the most predominate being from landmines. People therefore tend to limit the amount of water they use so that they do not have to travel too much compounding unsanitary conditions.
Some ceasefire groups made promises to provide communities with water tanks. This would help improve people’s access to clean drinking water and an adequate water supply for sanitation purposes. However, the provision of these water tanks was conditional on there being no fighting in the area. The United Nations Development Programme also provides water tanks to villagers in Karenni State.
4.6.2 Sanitation
Among rural communities in Karenni State there is very little sanitation services or awareness of the issue. Many communities do not have basic toilet facilities and water supplies are often contaminated. In Karenni communities where there are facilities they are often unused as villagers are unaware of the potential health risks or simply choose to follow traditional practices. Globally it is estimated that 5 million people die from preventable water borne diseases as a consequence of unsatisfactory hygiene and sanitation practices. Preventable illnesses arising from inadequate sanitation add further pressure on an already failing health system.
4.7 Public Health Education
Villagers have little knowledge of good hygiene and sanitation practices that reduce the risk of illness. Awareness among the general public is an important aspect of improving the health situation in Karenni State.
“Between 1994 and
1996 seven or eight villagers died of diarrhea in one village.
The outbreak was most likely caused by poor sanitation and
a lack of health education in the area. Villagers did not
know how to take protective measures during the outbreak of
the disease”, a midwife from Kxx Lxxx village tract said.
However, there are limited opportunities for trainings or awareness raising campaigns. Travel restrictions mean that health workers need permission from the SPDC to access certain areas and this is rarely given.
“In Nxxx Lx Bxx Sxxx
village, near Loikaw, the capital of Karenni State, there
is a fee clinic supported by MSF-Switzerland. Health workers
from the clinic provide health education programmes to the
villages nearby. However, the workers are unable to travel
to other areas and conduct these trainings, due to travel
restrictions imposed by the SPDC,” N--- R-- said.
Cross border health workers cannot spend extended periods of time in villages as their presence is a security risk for themselves and community members. Consequently they are limited in their capacity to raise awareness of health issues and good health practices within villages.
When trainings are offered, a lack of motivation or interest makes it difficult to find participants for these trainings. People depend on agriculture for their livelihoods so time spent away from their work affects the yield of their crop and their ability to feed their families. Villagers also worry about their security and believe that people may become suspicious. This poses a serious threat should SPDC troops came to the village and question other villagers about where they were.
A level of mistrust between different villages further deepens this crisis. Some villagers fear that if they attend health training, other participants would betray them and inform the military.
O- T- L---’s Story
In Loikaw there are two hospitals, a public hospital and a military hospital. O- T- L--- had served with the Burmese army for 27 years. After O- T- L--- retired he received a pension from the Burmese junta of 16,001 Kyat per month.
In 2007 O- T- L--- was ill. He went to the public hospital stayed in the hospital for four days. While he was in hospital he spent 84,800 Kyat.
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Item
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Cost (in Kyat
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Admission Fee
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500
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Blood Test (per test)
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5,000
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Exam Room Rent
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2,000
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Salavia Test (per test)
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1,000
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Food
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41,600
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Carer (per day)
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100
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Sterilised Gloves (per pair)
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25
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Prescription Fee
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80
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Bathroom Fee (per use)
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12
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All the hospital provided was the bed. O- T- L--- had to buy everything else. He needed to bring his own bedding, or buy some. When he required medicine or food he had to give money to someone to go outside the hospital and buy it for him.
When O- T- L--- was a soldier he had been to the military hospital. He said the military hospital was much better and that the SPDC provided everything. “If the people are sick, they will go to the local hospital, but the hospital is not there to save lives,” O- T- L--- said.
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Footnotes
33 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm , accessed November 2007
34 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
35 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
36 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
37 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
38 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
39 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
40 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
41 “Chronic Emergency: Health and Human Rights in Eastern Burma”, Back Pack Health Worker Team, 2006
42 World Health Statistic 2007, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
43 World Health Statistics, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
44 World Health Statistic, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
45 World Health Statistic, http://www.who.int/whosis/database/core/core_select_process.cfm accessed November 2007
To read other sections of the report please use the links below:
Executive Summary
Introduction
Oppression
Livelihoods
Education
Drugs
Internal Displacement
Threats to Regional and Internationl
Stability
Recommendations
Appendices
To email BI about our report, Living Ghosts, or the situation in Karenni State please click this link.
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