Borderline Health
As a "slow-motion genocide" envelops ethnic minorities in eastern Burma, health workers rely on innovative strategies and raw courage to save the lives of mothers and infants.
The two medics were running to keep up with the young man as he led them through the jungle in eastern Burma. They would reach his village in 90 minutes if they ran all the way.
On that hot afternoon in April, the man had come to Thaw D- village seeking help for his 17-year-old wife. She was nine months pregnant with their first child. When he'd left her at home, her body was jerking with seizures, her eyes rolling back. When he reached the clinic—a one-room bamboo hut—he was so short of breath that he could barely speak. Maternal health worker Naw Tha Mu grabbed the black emergency backpack, called an assistant to come along and followed the husband into the jungle.
Naw Tha Mu had met the woman and her husband the month before, soon after they arrived in the district. The army had invaded their former village and burned it down; Burmese soldiers often torch villages to assert control in their long civil war with Burma's hill peoples. The couple lost everything. They settled near Thaw D- village after hearing about the maternal health workers there.
They'd come to Naw Tha Mu's clinic in March because of the woman's headaches. Naw Tha Mu had given the woman iron for anemia and medicine for high blood pressure. She'd found protein in her urine—a bad sign when combined with high blood pressure. Now, a month later, the seizures signaled that the woman had developed eclampsia, which threatens the lives of both mother and child.
As Naw Tha Mu, 27, traversed the mountain path, she thought of her cousin who had died in childbirth three years before. They had been the same age. After giving birth to a stillborn baby, her cousin had bled to death. There had been no doctor within reach, no skilled midwife, no drugs to stop the hemorrhage. That was not unusual: Burma as a whole has one of the worst health care systems in the world. And the little that Burma does offer is generally denied to villagers in the frontier states of eastern Burma, where ethnic soldiers have resisted the Burmese army for 60 years.
Naw Tha Mu knew that she, too, was in danger as she pushed through the brush and bamboo. They were traveling in a "free-fire zone," where Burmese soldiers are authorized to shoot on sight. Carrying medicine put them doubly at risk. The army contends that anyone with medicine is aiding the rebels.
She had not stopped to ask if travel was safe that day.
Burma's health care system was ranked 190th of 191 nations worldwide by WHO in 2000. That ranking reflects Burma's priorities: the government spends about 3 percent of its budget on health and 40 percent on the military, which has ruled Burma since 1962. (The junta has renamed the country Myanmar, a name widely rejected.)
The conflict in eastern Burma has eroded public health. Burmese soldiers routinely force villagers to work without pay—even pregnant women—cutting wood, clearing landmines and building roads. When family labor is diverted, harvests suffer. The army commandeers local men and women by the hundreds to serve as human mine sweepers and porters. Women walking alone risk rape and murder. The army has torched or forced abandonment of more than 3,200 villages since 1996, uprooting a million people, according to the Thailand Burma Border Consortium.
When villagers hear that the army is coming, they run. Sleeping outdoors without mosquito nets, they face a high risk of malaria. Even the rudimentary health care that villagers can provide for one another is disrupted when communities are dispersed. One baby out of 20 is born to a woman hiding in the jungle.
Some observers call this a "slow-motion genocide."
Ten years ago, when Naw Tha Mu was a teenager, a multi-ethnic group of medics came together to fill the health care void in eastern Burma. These "backpack" health workers—today numbering 300—travel on foot to treat sick and injured people. Beginning in 2000, the Back Pack Health Worker Team also began to quantify the effects of violence and displacement on civilian health.
"No one knew what the levels were for very basic health indicators like maternal and child mortality, perhaps two of the most basic yardsticks to measure the health of a population," says Luke Mullany, PhD '05, MHS '02. An assistant professor of International Health at the Bloomberg School, Mullany is affiliated with the School's Center for Public Health and Human Rights, which uses science to support communities whose health is threatened by human rights violations. He also volunteers with the Global Health Access Program (GHAP), a California-based nonprofit that gave technical advice to the Back Pack team.
The Back Pack surveyors found that one in 100 women was dying in childbirth—25 times the rate for maternal mortality in neighboring Thailand. Nine out of 100 babies were dying in their first year; one in five children died before age 5. The death of Naw Tha Mu's cousin and baby was a commonplace event.
"The mortality rates were shockingly high," says Mullany, "especially when compared with the rates in Thailand, just across the border."
The Back Pack Team's 2006 report, Chronic Emergency: Health and Human Rights in Eastern Burma, also analyzed the impact of specific human rights violations on health. Forced relocation almost tripled the death rate for children under 5, and it increased the likelihood of landmine injury by 4.5 times. Helping the Back Pack Health Workers to establish the effects of dislocation fit with the work of the Center for Public Health and Human Rights. Center investigators showed that a child's risk of death in eastern Burma increased fivefold if that child's family suffered three or more violations of human rights. Authors of the study, published last year in the Journal of Epidemiology and Community Health, included Mullany and the founder of the Center, Chris Beyrer, MD, MPH '90, an Epidemiology professor at the Bloomberg School.
The connection between human rights and health drew Mullany to the work he does now. After graduating from college in 1997, he was volunteering for a public health project in Angola when he first recognized that health might hinge on politics. "It hadn't occurred to me that children would miss out on polio vaccinations because there was fighting or land mines, or no 'cold chain' [system for delivering refrigerated vaccines]."
In Burma, stories of brutality had been collected for years by Human Rights Watch and the Karen Human Rights Group. But, as Mullany points out, when people in power are confronted with an account of wrongdoing, "What's the typical response? 'That's an isolated incident. That unit has been disciplined.' ... But if you have quantitative data, you can argue: 'No, that's not an isolated occurrence. We did a population-based representative survey that showed the percentage of the population that's been forced to move, whose food supply has been stolen, who has been forced to relocate, faced forced labor, faced direct attacks.' "
Collecting data also locates pressing needs. A survey by the Back Pack medics showed that pregnant women in eastern Burma got very little health care. This worried the ethnic health departments that manage health care in regions of Burma abandoned by the central government. They had trained traditional midwives to attend births. But when they saw the high perinatal death rates, says Mullany, they realized that "in order to save women's lives, you need people who are trained to provide emergency obstetric care."
The ethnic health departments decided to provide that training. In 2005, they established a pilot program, the Mobile Obstetric Maternal Health Workers Project—nicknamed the MOM Project. They began with a target population of 60,000 in four eastern frontier states (Shan, Karen, Karenni and Mon states). Mullany and Beyrer advised the project, which received a large portion of its $200,000 annual budget from the Bloomberg School's Bill and Melinda Gates Institute for Population and Reproductive Health.
The aim of the project—safe delivery—is not unusual, but its novel approach reflects the geographical and political realities of eastern Burma. The conventional way to improve perinatal survival is to get women into well-equipped clinics with trained staff. But in a war zone, as Mullany puts it, "a focus on facility-based delivery is not a feasible short-term option." Even the rudimentary clinics that MOM has built have been vulnerable to army attack, and more permanent structures would attract unwanted attention. Furthermore, centralized clinics may be several days' walk from remote villages, and changing routes to avoid soldiers can delay travel by days or weeks.
So the MOM Project trained mobile health workers, equipping them to handle emergencies in women's homes. "That's what makes the MOM Project unique," says Mullany. "It's about bringing the services to the people rather than bringing the people to the services."
Soon after her cousin's death in 2005, Naw Tha Mu heard about the MOM Project. She'd already completed basic medical training, and the Karen Department of Health and Welfare chose her to be among the project's senior maternal health workers. In August 2005, Naw Tha Mu crossed into Thailand to join 32 other men and women for eight months of study in the border town of Mae Sot. They got hands-on experience attending births at the Mae Tao Clinic, founded by the revered Burmese doctor-in-exile Cynthia Maung, MD, who started the free clinic to care for refugees after the Burmese government killed thousands of student demonstrators in 1988. Maung helped design the MOM Project, and her clinic provided the volume of practice that the trainees needed: about 2,000 babies are born there each year. The project's field coordinators, first Catherine Lee, MPH, and now Kate Teela, MHS '08, have run the program along with five full-time staff from Burma.
The students learned routine care, including screening women for anemia and malaria (which can increase postpartum bleeding), resuscitating newborns in distress, and advising mothers about contraceptives ranging from condoms to Depo-Provera. They learned to use medication to reduce blood pressure and fight infection, and to remove a retained placenta after birth or miscarriage. They learned to use drugs to prevent postpartum hemorrhage, the leading cause of maternal death worldwide, and to give blood transfusions to treat it.
The 33 senior maternal health workers went home to run two months of training for 131 midlevel health workers and briefer sessions for 288 traditional birth attendants. Every village would have a traditional birth attendant, along with a midlevel health worker in the village or nearby. Senior health workers like Naw Tha Mu went to live in centrally located villages, ready to travel.
One key aspect of emergency care—blood transfusion after hemorrhage—had posed a problem. Without refrigeration in the clinics, how could blood be stored?
So the MOM Project innovated a plan for "walking blood banks" composed of villagers. The senior maternal health workers would type the blood of anyone volunteering to donate and save that information. In an emergency, runners would search the village and the rice fields to find several donors with the required blood type. The health workers would screen them on the spot with rapid diagnostic tests for diseases like malaria, hepatitis and HIV. Those who tested negative could give blood immediately.
The walking blood bank has proven successful, and the Bloomberg School's Beyrer thinks it could save lives in any place without refrigerators. "The blood is stored in the healthiest place there is: the human body," he says.
Donated blood saved a 34-year-old pregnant woman in Karenni State last year, says senior maternal health worker Aka Kyeh Pwin. After being bitten by a venomous green snake, the woman was bleeding heavily from the vagina, her cervix dilated. Aka Kyeh Pwin sent runners to search for the 10 potential blood donors in the village. Four people arrived, and all tested free of disease. Together, they donated five units of blood. The baby born the next day died after taking two breaths. But the mother of four children was well within a month. "She would have died without that blood," says Aka Kyeh Pwin.
It's late August, and Teela, the MOM Project coordinator, is counting villages. Sitting in an open-sided cinderblock building with a leaf roof on the outskirts of Mae Sot, she compares two lists of villages. She needs to calculate how many settlements in the MOM target area have disappeared and how many new ones have been established. As usual, a few villages have disappeared, and others are new. No clinics have been lost, though; in 2006, one of the 12 was burned by Burmese soldiers. Teela needs to know the number of villages so she can make 11th-hour adjustments to the plan for a population-based survey of the families served by the MOM Project.
Teela is elated that 14 of the 16 members of the survey team have made it to Thailand to prepare for the final MOM Project survey. Twenty-one maternal health workers have come, too. Some have traveled for days to get here, on foot, by motorbike, in boats and in cars. They meet, eat and sleep in open buildings beside a field where cattle graze.
The survey team has already completed baseline and midpoint surveys. Because eastern Burma generally has no postal system and surveys must be returned by hand, the final surveys will "trickle back," says Teela. They will be delivered by medics from other health programs who are passing through MOM villages en route to Mae Sot, which is home base for many cross-border projects.
The fact that she and Mullany can't directly supervise the surveyors complicates the task of controlling the quality of data. For instance, Teela and Mullany noticed that mortality rates for one area were triple the rates elsewhere. When Teela got a chance to talk to the surveyor, months later, she found that the surveyor had misread the question. Instead of asking how many people had died in a household in the past year, she had asked if anyone had ever died. Those numbers could not be used.
"We do our best to have these amazing trainings, but when it's done, we just have to hope the surveyors got what we'd hoped out of it and that they go back and do the best job they can," says Teela.
She and her colleagues monitor security conditions every two weeks, mostly by word of mouth. When villages are invaded, supplies that are lost or destroyed must be replaced. Sometimes data sheets are lost, too. "If a site has security problems for three months, it may explain why we have so many fewer pregnancy record forms than usual," says Teela. Despite all these logistical challenges, the project managed to get a 98 percent return on the midpoint survey.
Mullany and Teela are reluctant to judge the effectiveness of the MOM Project before the final surveys are evaluated. In any case, the surveys don't try to gauge changes in maternal mortality rates; the numbers are too small, says Mullany, because even where rates are high as in eastern Burma, from a statistical standpoint maternal death is rare. But he says that access to care can serve as a proxy for changes in survival rates. And access has dramatically increased: At the start of the study, 60 percent of women giving birth had no attendant at all, and only 5 percent had a skilled birth attendant comparable to a senior maternal health worker. Eighteen months into the project, more than half the women surveyed had given birth with help from a midlevel or senior maternal health worker.
MOM's director of training, Palae Paw, notes that this is the first program to systematically provide emergency care to pregnant women in eastern Burma. "They feel like their lives and their newborns' lives are more valued," she says. Mullany feels confident that the approach merits adoption elsewhere. "Expanding the level of skill of people working directly in the community is a model worth pursuing," he says.
The pilot project will be complete once the final surveys are evaluated, but the MOM project will continue. The Mae Sot-based Burma Medical Association will manage the program, and expand it, with funds from nonprofit groups in Thailand and beyond.
This kind of collaboration will continue even after the fall of the military regime in Burma, says Eh Kalu Shwe, the secretary of the Karen Department of Health and Welfare. When that day comes, he says, "We will invite GHAP people and Johns Hopkins University people to consult for public health and primary care for the people of the new Burma."
By the time Naw Tha Mu and the others reached the woman's side that late afternoon in April, she had suffered two more seizures. Naw Tha Mu gave her a magnesium injection to stop the seizures and nifedipine to bring down her blood pressure. Naw Tha Mu knew that the best treatment for eclampsia is to get the baby out, but she wanted to take her patient to the clinic, where she had more supplies than she'd been able to carry. The woman's husband and brother placed her in a cloth sling tied to a bamboo pole. They hoisted the pole to their shoulders, with the woman suspended between them, and the group set off for Thaw D- village. They arrived two hours later, just before dark.
Naw Tha Mu laid the woman on a straw mat, strapped on a headlamp so she could see, inserted an IV and gave her oxytocin to speed her labor. Two and a half hours later, she gave birth to a baby boy. His skin was blue-black, and his heart rate, at 80, was dangerously low. Naw Tha Mu moved fast: she injected the baby with adrenaline and began to breathe into his mouth. After five minutes, he began to breathe on his own. His heart rate quickened.
Meanwhile, the mother was bleeding. She had not delivered the placenta. While the husband stroked his wife's hand, the assistant health worker gave her misoprostol, which caused contractions that expelled the placenta. The bleeding stopped. The woman drifted in and out of consciousness all night, talking gibberish. But by morning she was conscious and nursing her baby. In a week, she had the strength to walk home with her son.
They have visited Naw Tha Mu twice since then. "I feel very happy to see them," she says. "If I had not been there, the mother and baby would have died."
Still, she has her fears and sorrows. When she was returning from Thailand from follow-up MOM training in October 2007, she saw Burmese soldiers on the road, and she ran, dropping the backpack with the drugs, contraceptives and medical forms that she'd need for the coming 10 months. She spent that night hiding alone in a cave before returning home.
Burmese soldiers invade her village often. "I can't count how many times," she says. Everyone runs. Recently, the soldiers came again. Her 43-year-old aunt and 13-year-old cousin fled in the wrong direction and met the soldiers face to face. "We don't know if they're alive or not. ... I can't think about what the soldiers will do to them," she says, and she turns her face away.
In July, after following a forest path to visit a patient in a nearby village, she heard that she'd missed stepping on a landmine by inches.
"I am working for my people," she says. "If I die, it's OK."