MSF: supporting ethnic minorities' efforts against malaria in Mon State ceasefire zone – Myanmar

Tens of thousands of ethnic Mon have been displaced in the decades long conflict between the Burmese junta and a Mon separatist rebellion in Southern Burma. The Mon, who belong to one of Myanmar's main ethnic groups, are mostly lowland people, but continuous harassment from the Burmese army and ongoing military operations in Mon State have prevented them from leading a normal life.

In 1995, the signing of a ceasefire between the Burmese government and the New Mon State Party (NMSP) led to the delineation of several ceasefire zones. Over 70,000  people are estimated to live there in villages for displaced or in resettlement camps along the Thai Burmese border.  The ceasefire areas remain under the administration of the NMSP and have provided a relatively safe haven for the displaced ever since. But the mountains and dense tropical jungle create a challenging environment for the population. One of these challenges is access to healthcare and Médecins Sans Frontières (MSF) is supporting the Mon National Health Committee's work to treat malaria and vaccinate children.

Sitting on the wooden floor of Halockani clinic, 26 years old Kinla is patiently waiting for her turn, amid the shouts and cries of children. Her two-year-old son, Ai Mon, feeling something unusual is about to take place, has tightly gripped her hand. Kinla is one of nearly two hundred women who have brought their children to the vaccination campaign organised by MSF in the resettlement area in the Mon state, not far from the Thai border.  The local health authority has informed the villagers that children under five will be vaccinated against polio, mumps, measles and rubella. As women huddle under the clinic's porch, MSF's teams begin checking children for malnutrition, before proceeding with the injections.

Ai Mon has never been vaccinated before and his mother is ready to wait as long as it takes. "I know it's important and there has been no recent vaccination campaign," explains his mother. Indeed, vaccination campaigns have been scarce in the NMSP controlled areas. MSF decided to work closely with the local medics after high numbers of measles cases among children under the age of five sparked fears of an epidemic.

"It's one of the things we can do to improve general health and it's important because the people who live in the jungle often have limited access to healthcare," explains field coordinator, Raden Srihawong.

MSF's current work with the Mon is based on a close relationship with the Mon National Health Committee (MNHC). Although there are nine clinics in the NMSP controlled areas, there are in fact no doctors and no nurses.  The healthcare system depends entirely on local medical workers (medics) and volunteers trained for six to nine months, who then spend several years working in various health posts. MSF aims to strengthen their capacity and medical knowledge in malaria.

"Medics' medical knowledge remains basic. They visit villages, some of them deep in the jungle and have sometimes to deal with very complex cases. We finance ongoing medical trainings but we are also rehabilitating the hospitals and running water and sanitation activities to improve water quality and waste management." explains Raden Srihawong.

The mountainous setting provides a breeding ground for mosquitoes during the rainy season and malaria is endemic in the region. MSF also finances trainings for lab technicians and provides drugs and rapid diagnosis tests to give the community the means to treat patients as quickly as possible. "When we first came, they had many patients suffering from malaria but only few treatments available and most of the microscopes were broken," remembers Srihawong. Since the project began in April 2007, MNHC's  teams have been able to treat nearly 6,000 patients for malaria and MSF is monitoring the cases recorded at the health clinics.

The real challenge when treating malaria in the area comes from the environment. During the dry season, Halockani feels like an agreeable village with traditional wooden houses and thatched roofs, but when the first rains come, the whole area turns into a mud pool. Roads literally disappear, wiped away by landslides, and the rivers swell, destroying bridges and flooding habitations. Mosquitoes thrive and people are stranded. Even the shortest trip turns into a skilful logistic exercise.

Balai Doung Pike is a cluster of houses, home to around 1000 people. It possesses its own clinic, less than 200 metres away from the heart of the village, yet rains can be so violent that the health post is cut off from the village during each monsoon.

"We must carry at least 6 or 7 sick people per month to the nearest accessible clinic six km away in Halockani, because the road to Balai Doung Pike clinic is simply impassable," explains 49 year old Mi Yin, a local resident. "They often have to wait a day until the rain stops or the river comes down."

Each trip to the hospital is a daunting expedition. It requires around seven men to carry a patient on bamboo poles wrapped in a lungi, the local garment.  "Men have to take turns every 15 minutes because it's very physical and tiring," describes Mi Yin, "they have to climb hills and cross five flooded rivers, it's often very slippery and they have to be careful not to fall." With so many obstacles, only the very sick get to go. In fact Balay Doung Pike is not far from the Thai border, most villages are much deeper in the jungle, and access to health care is even more difficult.

It's a reality that Super knows well. The 34 year old is slender but deserves his unusual name. After becoming a medic for the Mon National Health Committee, he joined MSF six months ago and is now one of the lab technicians and medics who provide healthcare in remote areas. To remedy the limited access to healthcare, the MNHC selects malaria workers in isolated villages. Volunteers are trained to identify symptoms and give first hand care.  Out of the 10 villages Super looks after, four are situated deep in the jungle. "I became a medic because I wanted to help my people, but you sure have to be fit,” he says with a shy smile, "It's pretty exhausting sometimes!"  His furthest trip is a four and a half day walk of ten hours a day through the dense tropical jungle. On his bimonthly treks, Super takes two fit porters with boxes of drugs. "In these villages, I diagnose and treat people on the spot. In general they suffer from malaria, pneumonia, skin diseases and respiratory infections and have nowhere to seek healthcare," he explains.

Healthcare options offered to the population living in the NMSP controlled areas are limited and, apart from MSF's support, the New Mon Health Committee has to rely essentially on its own resources and medics. In case of emergency, patients can be referred to Thai hospitals after requesting and obtaining permission from Thai authorities.

"Since we left the camps in Thailand we have gained more independence, but we are now much more isolated. We used to have many contacts with the international community when the Mon refugees were still staying in the camps inside Thailand.  Now, most of the NGOs have had to cut down or halt their support," regrets Nai Kasauh Mon, head of the Mon Relief and Development Committee.

MSF's work with the Mon began after a Burmese military offensive in the Mon State drove thousands of civilians across the border to Thailand in 1990. The population was allowed to settle temporarily in a camp in the border town of Sangklaburi and MSF begun providing healthcare to them in 1994.

In the wake of decades of conflict, a ceasefire was agreed between the New Mon State Party and Rangoon in 1995. Thousands of Mon who had taken refuge in Thailand, were relocated in the ceasefire zones. By 1996, all the Mon were sent into three main resettlement sites in Halockani, Bee Ree and Tavoy. Despite the ceasefire, splinter groups disgruntled with the peace deal continued their fight against the Burmese army in Mon State.  In response to the breakaway factions Yangon increased its troop presence in the area and clashes have persisted until now. The NMSP controlled areas have remained a sanctuary for the population of Mon state and they continue to receive a regular influx of newcomers.

But they don't offer a favourable environment to resume normal life. Quite apart from medical and transportation issues, there is also little arable land. "Land shortage is a serious concern. Although we are not refugees anymore we cannot farm here or be self reliant for food," explains Nai Kasauh Mon, head of the Mon Relief and Development Committee,  "There is no income, no livestock and a growing shortage of food, this is why we do not encourage newcomers to stay in the resettlement area." The ceasefire zone represents only 10% of the Mon state territory.

According to Nai Kasauh Mon, between 200 and 500 families seek refuge in the area each year. They run away bringing tales of forced labour, extortion and human rights abuses at the hands of the Burmese military. The newcomers can temporarily stay in villages for the displaced where they are provided food for 3 months before eventually going back to their own villages in Mon state.

Halockani is the main resettlement site in the ceasefire zone along the Thai border.  Although in effect it is a cluster of villages, it is commonly referred to as "camp". "For us normal life means having a two-floor house, oxen and a rice field. But people in Halockani have no rice stock, no livestock, no chilli and no fish paste," explains Nai Kasauh Mon, "The mountain life is not good for us, there is not enough water, not enough land. This is no normal life, this is survival."

If at first, the ceasefire zone was perceived as a positive step towards peace, 13 years down the line, hopes for a better life have been tempered and have given way to a growing sense of frustration. "Some families have lived in Halockani for over ten years now, nothing has really changed and many people are disappointed," Nai Kasauh Mon confesses.

The younger generation shares the malaise of their elders. In the ceasefire zone, many have neither Burmese nor Mon identity papers and the future looks bleak.  "Most people feel that the only option is to take a chance in Thailand and become an illegal migrant," explains Nyan Seik Rar Marn from the Mon Youth Progressive Organisation.

This often means a life of hardship, facing low-income jobs, possible exploitation from employees, a frustrating cat and mouse game with the Thai police and no access to healthcare. Still, the temptation is so strong that, according to Nyan Seik, even parents encourage their children to cross the border.

"A salary way under the minimum wage in Thailand is still much higher than what we'd get anywhere in Burma," explains Nyan Seik "Of course becoming an illegal migrant may not be the best life you could hope for, but for most young Mon it looks much better than life in Mon State and in the ceasefire zone, with no opportunity and, many feel, no future at all."

Cholera outbreak in Mon State

A team of 13 MSF staff was sent to support the Mon National Health Committee (MNHC) in the ceasefire zone after a suspected epidemic of cholera broke out at the beginning of March.

Samples sent to a laboratory by MSF confirmed a cholera outbreak.

MSF worked in close relationship with the MNHC to control the spread of the disease and treat patients in two health centres.

The team organised chlorination, ensured proper water supply and help implement a protocol for dehydration. MSF also provided health education to the population and the outbreak was quickly brought under control.

Five people died and 82 have been hospitalised since the beginning of the outbreak. 

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