Helping vulnerable migrant workers access health care in Phang Nga, Thailand
"They work all day, every day of the year, doing the jobs Thais refuse, for a pittance."
The girl with the perfect smile and ebony locks sits on her stool, a chewing gum poster of glowing youth. Beside her sits her husband, his face split by a goofy grin of pride. They are newly weds, full of the hopes and dreams universal to young couples around the world. They are also new arrivals: Burmese migrants who only today touched Thai soil for the first time. Even their beaming smiles can't disguise their evident bewilderment and fear. They have arrived in a land where they don't understand a single word, can't read a sign and if they fall sick or have an accident, have absolutely no idea who to turn to.
In Phang Nga, a province bordering the famous tourist island of Phuket, tens of thousands of Burmese have made boat crossing or trekked overland to reach Thai shores. They come to work on the construction sites, the rubber plantations or the fishing boats and whether they are fleeing persecution or destitution in their native land they have the same goal in mind: to make a better life. But a shot at a better life comes with risks. Although the Burmese migrants form the backbone of the low-paid labour force here, many can't get the legal documents that entitle them to health care and education. They remain illegally, and their precarious status means lives led in constant fear of arrest and intimidation by Thai authorities. This in turn makes them insular and wary of outsiders, thereby preventing their integration, and leaving them isolated and vulnerable.
The young couple explain why they would leave behind their families for such an uncertain and potentially dangerous future:
"ack in Burma we lived as part of a big family but we were the only ones who could find work. The political situation in the country makes life very unstable. We made just a dollar a day, and this was barely enough to feed us all. So we decided to leave our homes and come here in the hope we could earn more and send some money home."
To get here they endured two days cowering in the bottom of a tiny, crowded boat, as waves kicked up by a storm dwarfed the leaky hull. The wife thought she was going to die. Waiting for them at the end of their journey was their new home: a single mattress on the floor of a toilet-sized shack, not even tall enough to stand in and hastily erected in the shadow of the multi-story luxury resort they are constructing.
Phang Nga was the region of Thailand worst affected by the December 2004 tsunami. Prior to this there were over 30 000 registered Burmese migrants in Phang Nga alone, with the same number again here illegally. Many were victims of the tsunami. While no official figure has been provided, local grassroots organizations reported more than 1000 missing Burmese.
When MSF came to the area to offer emergency relief, it found tens of thousands of Burmese workers, traumatised and destitute. Medical relief to Thai nationals and Western victims was well organised but Burmese migrants remained largely invisible. Denied relief by their own government and overlooked by international efforts, many returned home in desperation. But the ongoing violence in their country and the promise of jobs in Thailand, particularly with the rush to rebuild hotels, has brought many back. And whether legal or illegal, lack of information, fear of persecution and cost mean most are excluded from even basic health care.
Explains MSF' Medical Co ordinator Dr David Wilson: "To get to a hospital some migrants in the area have to pass check points that could lead to their arrest, and when they arrive at the hospital they have no means of deciphering the signs or directions, or communicating with the medical staff. And at the end of it all, they receive a huge bill that is more than they can afford. Even those migrants who are legally entitled to health care and can receive treatment for free have no idea of their rights. So they don't go."
The inaccessibility of health care is having a clear impact with health indicators for Burmese migrants plummeting below those of their Thai neighbours. Mother-child health is particularly poor and every month another Burmese baby dies out of an average of just 25 births. Most deliveries are at home, in poor conditions, often under the supervision of a traditional birth attendant and very few women use any form of contraception, even if they do not want to become pregnant.
Sexually transmitted infections (STIs) and HIV are another growing problem, due to poor health education, the predominance of lone men and the higher levels of STIs in Burma. MSF has identified at least 90 HIV+ patients who are sick enough to require antiretroviral treatment. But because they are classified as mobile groups, even those with health cards are not provided with the treatment. Tuberculosis poses another problem with sick workers having no place to stay, and poor, cramped living conditions making the risk of transmission high.
To address these problems MSF has set up a number of initiatives to improve migrant workers' knowledge and understanding of health and increase their access to care. This is achieved through a combination of mobile clinics, home visits, activities in health centres, hospital support and education in the community.
Outreach teams identify migrant worker communities and pave the way for health educators and mobile clinics to come and inform workers about family planning, STIs and what to do in case of health emergencies. MSF's doctors and nurses treat what ailments they can on the spot and refer more serious cases to hospital, covering the costs if necessary.
MSF also runs two health clinics and a primary care unit specifically targeting migrants, with signs, information and services in Burmese. In two hospitals MSF's bilingual volunteers offer translation services, pre and post HIV test counselling and health information sessions.
One of the problems faced by some migrants with infectious diseases such as TB is that when they are too sick to work, they have nowhere to stay and no means to live. As well as securing their medical treatment, MSF has provided a safe house for TB and HIV/AIDS patients that would otherwise be out on the street. One of these patients is Yang, a 42 year old fisherman.
For weeks Yang lay inert in the stinking bowels of a commercial boat, too sick to move, but unable to get off until the vessel returned to port. He was soon hospitalised and diagnosed with TB and HIV, but although the TB was treated, he could not access the HIV/AIDS treatment available to Thais. When MSF found Yang he weighed just 45 kg, he could not walk, had gone blind in one eye, and lost the feeling in his legs. He was relying on the charity of neighbours to stay alive.
Yang now lives in the MSF safe house where all costs are covered and residents take turns in caring for each other, with medical staff visiting every week. But what distinguishes this from palliative care, and will hopefully save Yang's life, are the drugs he is receiving. Yang is now taking triple antiretroviral therapy. He is the very first Burmese migrant in the province to receive such antiretroviral treatment and MSF is determined he won't be the last.
Back at the construction site, the young husband is in deep conversation with the MSF doctor from the mobile clinic. He would like to start a family soon and enthusiastically asks the price of a hospital birth. But his face drops the moment he hears the sum: it's more than two month's wages. This is an issue MSF is looking into but for now the newlyweds agree that family planning is perhaps the best solution. Their attention swiftly refocuses on the reproductive health information session going on beside them.
Phang Nga is a tourist destination dotted with luxury spas and dive boats. But for these young workers crowded into make shift camps with poor hygiene and no facilities life is never going to be easy. At least by arming them with health education, helping them understand their rights and offering them health care either directly or through the health system, MSF is ensuring they don't suffer avoidable health risks as well.
"These people have exchanged political persecution and poverty for exploitation. They work all day, every day of the year, doing the jobs Thais refuse, for a pittance. But many have nowhere else to go. The very least they deserve is their health," concludes MSF Dr Wilson.
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