Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Public Health Problems on Burma Frontiers
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away. I met many frightened young people who did not know they cannot get HIV
from handshaking and touching the infected person.
The obvious language and cultural barriers are one of the obstacles NGOs face
in conducting public health education on the border. The border population is complex,
with people originating in different areas carrying a strong sense of ethnic
identity and their own health belief systems. Between care providers and the local
population there is also a gap in understanding and perception of human diseases.
In such circumstances, there is almost a complete lack of continuity of care. As a
result, the effectiveness and sustainability of the health education system on the
border is less than optimal, despite much effort in terms of money and manpower.
The greatest frustration in dealing with these medical challenges along the
Thai-Burma border is the knowledge that all are rooted in problems inside Burma—
the political and social conditions that drive people across borders and the lack of
basic health care infrastructure and education in the country. Knowing that for
every malaria case we could treat, five more would be coming from Burma with no
knowledge of how the disease spreads and how to avoid drug resistance. Knowing
that for every migrant worker we could teach to avoid AIDS, more would be coming
already infected with the virus. Knowing that under present conditions in Burma,
we cannot hope to set up inside the country even the inadequate health infrastructure
that exists in the border region today.
One measure of the problem inside Burma is that there are very few reliable
measures of the problem. Comprehensive public health research is impossible in a
country where official statistics have been known to be inaccurate, and institutions
independent of the government cannot freely operate. But UN estimates suggest
that between 400,000 and 700,000 people are infected with HIV out of a population
of 45 million, making Burma one of the four hardest hit countries in Asia,
along with India, Cambodia, and Thailand. Burma has an estimated half million
heroin addicts, and the HIV infection rate among IV drug users is the highest in the
world, according to the WHO.
We know that Burma has multiple risks and vulnerabilities: needle sharing among
addicts; an unsafe blood supply and lack of universal precautions in health care
settings; heterosexual transmission facilitated by a growing local commercial sex
industry; the trafficking of Burmese women and girls into the regional sex industry;
untreated STDs; very low condom use and availability; cultural traditions that deter
people from talking about the behavior that spreads AIDS, though they don’t seem
to prevent people from engaging in the behavior itself.
Under normal circumstances, we could devise strategies to deal with each and
every one of these vulnerabilities. Unfortunately, each and every one would require
a national effort strongly backed by the government of Burma. The government, to
this point, has shown little interest in such an effort. Public health needs of the
Burmese people have been systematically neglected. Instead of growing to meet a
public health emergency, Burma’s public health infrastructure has been shrinking.
The problem has not been one of poverty—but of priorities.
I saw some of it growing up and in my years as a medical student in Burma, but
the situation has grown worse in the last decade. According to the UN, Burma
spends 222 percent more on its military than on health and education combined.
Only three countries in the world have a worse ratio. The number of hospital beds
in the country declined by one-third between 1986 and 1996 at a time when the
military doubled in size. Burma is an epicenter of the southeast Asian AIDS crisis,
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