MAE SOT, Thursday, November 6, 2008 - It was a routine, sweltering mid-April day for Naw Say, a medic treating internally displaced persons (IDPs) in Karen State's Takreh Township, just one kilometer from the Thai border.
Mothers cradled crying children, giving Naw Say the opportunity to place two drops of polio vaccine into open mouths.
Immunization sessions not only prevent crippling diseases like polio, they also give medics an opportunity to gauge the overall health of IDP children, whose families come from far and wide for care. The most common complaints are malnutrition, diarrhea, malaria and respiratory infections.
This day appeared at first to be no different from others, until the presence of several children with similar symptoms set alarm bells ringing for Naw Say.
"There were five kids on that first day," she recalled. "They had a cough, conjunctivitis [pink eye] and a red rash all over the body." Naw Say asked the parents if there were any more children with these symptoms in their village. "They said yes-many."
Naw Say's heart sank. This was almost certainly measles, a vaccine-preventable disease. Although the fatality rate of measles is low, the highly contagious virus can spread quickly, especially where malnutrition is rife and healthcare systems almost non-existent.
The five children examined by Naw Say that day heralded the start of the largest outbreak of measles documented so far in the IDPs of Karen State, threatening a total population of 16,500.
Naw Say and her colleagues quickly collected blood samples to send to a Bangkok laboratory for confirmation. At the same time, a team of medics delivered measles vaccines for a catch-up immunization program, following World Health Organization guidelines.
The tests confirmed a measles outbreak, affecting several districts of Karen State. By the time it was controlled in September, 512 people had fallen ill and four had died.
The outbreak could have been far more severe. In five months, medics immunized over 7,700 children, 87.1 percent of those living in and around the affected areas, including districts deep inside Karen State. The border-based intervention curbed the spread of the virus-at least for the time being.
Burma's once vaunted healthcare system is yet another casualty of decades of military rule. The current junta, the State Peace and Development Council (SPDC), spends the equivalent of less than half a US dollar per capita annually on health and provides no childhood vaccines, perhaps the most cost-effective public health intervention available.
Today, UNICEF provides 90 percent of the vaccines given to Burmese children. But the vaccines rarely reach children living in the conflict areas of ethnic states. In stark contrast, the Thai government's equivalent figures are $61 and 100 percent. The result is that 10 percent of Burmese children die before their fifth birthday, the second highest childhood mortality rate in Asia after Afghanistan.
The situation is even more dire in the conflict zones of eastern Burma, where ongoing clashes and widespread abuses of civilians have forced more 500,000 people to live as IDPs, including 66,000 who have been displaced in the past year alone, according to the Thailand Burma Border Consortium.
"When the SPDC forces villagers to flee to the jungle or to IDP camps, their health status falls because they do not have good access to food.
Then when they catch diseases like malaria or measles, they have serious complications," said Saw Eh Kalu, secretary of the Karen Department of Health and Welfare (KDHW), a border-based group that led the measles control response.
"In the IDP camps, measles outbreaks also infect many people because everyone is living close together."
Almost one quarter of IDP children do not survive to see their fifth birthday, a figure comparable to Angola or the Democratic Republic of the Congo, and almost all childhood deaths are a result of malnutrition and infectious diseases.
Yet despite the severity of the disaster facing the IDPs of eastern Burma, international humanitarian organizations, including UNICEF, are barred from accessing these people and providing aid. Reminiscent of the junta's immediate response to the devastation of Cyclone Nargis, an $11 million UNICEF measles immunization campaign in 2006 targeting 13 million Burmese children was threatened and delayed as the Burmese generals ascertained whether it was "politically safe."
For local health organizations attempting to provide some basic health services in the conflict zones, the consequences are often severe. Since the inception of the Backpack Health Worker Team, which also provides care to Burma's IDPs, seven staff members have been killed. Intimidation and harassment are common, and clinics and health programs have been forced to cease operating as a result.
"During this outbreak four areas reported measles outbreaks, but we could reach only three areas," said Saw Eh Kalu. "To get to the fourth area, you have to cross an SPDC road, but this can take several days or even one week because of security. We have to keep the vaccines cold with ice."
This outbreak and the ongoing crisis facing IDPs of eastern Burma have implications for health that extend beyond the Burmese-Thai border, especially in light of ongoing restrictions on humanitarian aid for these populations. An estimated 2 million Burmese migrants live in Thailand, including many who have fled from conflict and abuses at home. The vast majority are undocumented and unable to access healthcare services, including preventive programs such as childhood immunizations.
Until the underlying realities of Burma's health vulnerabilities are addressed, outbreaks of vaccine-preventable illnesses will continue to serve as deadly reminders of the junta's failure to govern responsibly, said Saw Eh Kalu.
"The international community needs to think about the dignity of IDPs and their right to a life of peace and progress," he said. "We need assistance not only to solve the IDPs' health problems, but also to cure Burma's deeper political illness."