Myanmar’s Health emergency

IN Myanmar’s eastern Shan state, in the golden triangle between China, Laos and Thailand, people were getting sick. No one knew why they were getting sores on their skin and wasting away. Maybe it had something to do with people leaving their mountain villages and crossing the borders to work in restaurants or massage parlours, or on construction sites.

No one talked about the new illness. Just as they didn’t talk about children who had constant diarrhoea. Or about adults with regular bouts of fever and shaking chills — classic symptoms of malaria.

In many rural villages, says Yvonne Ginifer, a health delegate with the International Federation, people didn’t even know how their behaviour influenced their health.

“The people of one village didn’t have any understanding of the concept of health. They didn’t even know when they were sick. They didn’t know they could do anything about their health. They had a ‘go with the flow’ attitude.”

Now the silence is ending. It’s hard to know how many people in Myanmar are HIV-positive. The government says the number is 177,000. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates the number might be as high as 1 million, and warns that Myanmar might be on the brink of the most serious epidemic in Asia. Many cases aren’t reported and deaths are often attributed to tuberculosis, diarrhoea or malaria. Unlike other Asian countries, infection rates in Myanmar are continuing to rise.

Reaching out to rural communities

For the past two years, the International Federation and the Myanmar Red Cross Society have been working to reduce the incidence of endemic diseases and the spread of HIV in eastern Shan state, a region with a highly mobile population. The Chinese border is just 85 kilometres from the state capital Keng Tung; the border with Thailand is 160 kilometres away. There is anecdotal evidence that traffickers recruit women from this isolated, cut-off area for sex work.

The Australian Red Cross and the Australian Agency for International Development fund a three-year community-based pilot health project, costing more than US$ 380,000.

Starting with basic health information, Red Cross staff and volunteers have gradually won the trust of people who survive on small, isolated farms and often have little or no access to education. Gradually, they have been able to broach the taboo subject of HIV and the myths and misconceptions surrounding it.

“When I started, HIV wasn’t a topic of conversation,” says Ginifer. “But now it is. People are intelligent and hungry to learn. Until now there’s been such a lack of resources and information. People don’t know how to protect themselves from HIV. It isn’t something that’s discussed openly in Myanmar, let alone in these little villages near the border.”

Fitting local realities

The Red Cross faces plenty of practical obstacles. In some villages, people spend days out in their fields during certain times of the year, making them hard to reach. In the rainy season, hillside roads turn into mud and rivers become impassable.

Other difficulties are cultural. Each village is unique, with its own mix of languages and ethnic groups including Wa, Kachin, Shan, Akha and Lahu. To reach its audience, the Red Cross recruited volunteers from different ethnic groups. Then educational material had to be developed, translated and tested to make sure it was appropriate to different cultures. These volunteers then work in their own or neighbouring villages.

Often villages have their own political system. Wan In village, for example, has a new village headman every week. It’s a job that rotates among a group of male elders in this Buddhist village where people are from the Shan ethnic group. So every time the Red Cross came, they had to speak to a new man and win him over.

Still, there have already been improvements, such as in reported cases of dysentery or diarrhoea. Village shops report they’re selling more mosquito coils and fewer pills to treat malaria.

In fact, the improvements in two villages visited by the Red Cross aroused the curiosity of the people of Wan In village, says an elder. “We saw two other villages become clean and healthy and we wanted it too.”

Twenty-three people from Wan In, a village of 135 people, have already been introduced to the basic concepts in a community-based first-aid course. It was a struggle to get women on the course, in a village where men are always put forward first. What was the most important topic in the course? Three young women who have been trained are too shy to answer.

Another woman, Pa Sein, 40, replies: “The most important thing I learned was how to treat injuries, like cuts you get in the paddy field. Health education is a new topic for us, so we’re interested in everything.”

Pa Sein has three children, aged 15 to 25, and one grandchild. “I now know how to care for women who give birth. In the past we gave birth by ourselves if it was a normal birth, or we went to hospital if there were problems.”

Neighbouring Hu Nar village, home to 216 Christians belonging to the Kachin ethnic group, has worked with the Red Cross for 20 months. The headman supports this collaboration, which includes monthly health talks, training and technical assistance with water and sanitation.

“Before we knew the Red Cross name but we didn’t understand it,” says the headman. “Now we can understand what the Red Cross is doing. I’m proud to work as a Red Cross volunteer for the village. We can see a big improvement in living conditions in Hu Nar.”

Changing behaviour

Some traditional remedies remain. People drink water infused with a herb to cure diarrhoea. And they scrape the neck with a coin to take away pain or fever. Mo She shows us vertical red marks on his neck from where he pinched the skin to cure a cough, which is nearly gone now, he says.

Ginifer says some of the other remedies were riskier. “When we asked them what their preferred first treatment was, a lot of people said injections. There were a lot of injections around but what they were, we didn’t know.”

Baptist minister Kom Kwe says people have fewer injections now — so they are saving money as well as avoiding health risks.

Once people see the basic health care knowledge working, they come back for help with more sensitive topics. Once a villager timidly told the Red Cross that there was someone with HIV in the village. Red Cross members visited the person and spent time with him, giving him encouragement. This surprised and impressed villagers, who had been so afraid of HIV that they had shunned the person. After the man died, the Red Cross took his very ill five-year-old son, also HIV-positive, to a clinic for treatment, where he gradually improved.

After watching this response, village elders, who had initially said the burden of caring for someone with HIV who was going to die anyway was too high, asked the Red Cross to provide training in the care of people with HIV/AIDS.

As well as working on basic health education in remote villages, the Red Cross concentrates on people in the state capital Keng Tun whose behaviour might put them at risk: young people, construction workers and motorbike taxi drivers. Red Cross volunteers and staff train peer educators, hold discussion sessions, run campaigns and distribute educational materials and condoms. A Red Cross survey found 71 per cent of taxi drivers had had contact with a peer educator and had basic information about HIV, so the system is working.

Model for other regions

The Red Cross hopes the benefits of the pilot programme will spill out far beyond eastern Shan state, says International Federation head of delegation Joanna MacLean. Keng Tung branch could be a model for enhancing branches across Myanmar.

“It presents a move from a top-down way of determining priorities towards a community-based approach. Another departure from the usual is that it uses participatory adult learning concepts,” she says.

“So far the Keng Tung pilot project has been very promising. Staff and volunteers are growing in expertise and experience, and communities are participating with enthusiasm. Already rural communities are making changes in their behaviour, and we can see changes in their health. We think this project is extremely useful not just for the local communities and the Red Cross branches, but for developing the Myanmar Red Cross Society as a whole.”