Episode 9: Healthcare in Kayin State (English version)

In this week’s episode, we take a look at healthcare for the Karen people in the wake of 70 years of conflict. Have a listen below. 



Episode 9 script

JARED DOWNING: Hello, welcome to Doh Athan, a new weekly podcast from Frontier Myanmar, I am Jared Downing. 

Our pioneering audio programme, the first of its kind in Myanmar, helps shine a spotlight on the many human rights issues that affect people across this beautiful country. 

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This week we take a look at what’s being done to help healthcare for Karen people who have suffered from 70 years of conflict.

A cycle crash and a nasty gash brought Nant Aye Cho to Thailand.

Pwo Karen woman made her way down the mountain trails to the government hospital in Kawkareik, Kayin State with a bleeding foot and toddler in tow.

But the doctor wasn’t in, he was running some errand and the staff didn’t know when he would be back, and anyway they were less than thrilled to deal with a few village walk ins who couldn’t even speak Myanmar language.

So Aye Cho decided to leave Myanmar altogether and cross the border into Thailand, where she could check into a free clinic for migrants and refugees.

The clinic is called Mae Tao, in the town of Mae Sot, and it is there, that Aye Cho tells me her story. It had to be translated twice, first from Pwo Karen to the more common Sgaw Karen, and then into English.

She and the other patients are arranged in wheelchairs and wooden pallet beds. Some of them have lived on the Thai side of the border for years or even decades. Others, like Aye Cho, are here for only a day or two. 

The Mae Tao Clinic has become a sort of de facto hospital for the roughly 250,000 people living under Karen National Union authority.

After the 2015 ceasefire, the Myanmar government should theoretically be able to cooperate with the KNU and expand its public healthcare coverage. `in fact, The Ministry of Health and Sport is trying to achieve universal healthcare in five years and identifies or EHOs,  “ethnic health organisations”, as essential for that goal.

But to do that they need to a mire of bureaucracy, data gaps, language barriers, old prejudices and meeting after meeting just on how to get started.

To make things more complicated, there is a whole ensemble of independent Karen EHOs, names like DKBA Healthcare, the Karen Peace Force, the Burma Medical Association, the Back Pack Health Worker Team and several other organisations.

All of them have to get on the page. And while most have agreed to join the under of the largest Karen EHO, called the Karen Department of Health and Welfare, in the meantime, many in rural Kayin rely on scattered triage sites or the Mae Tao Clinic for their healthcare needs.

This is Saw Eh Say, he directs a KDHW clinic at the vollage of Thar Yar Gone, which exists in a kind of administrative grey zone between the government and the KNU.

To call it a “clinic” is a bit of an overstatement. Other than basic aid and medicines, its medics and volunteers mainly provide transport and referrals to other hospitals for the roughly 1,000 villagers in the area.

Most of the day’s patients arrive in the morning on motorbikes or cattle carts, seeking treatment for dysentery, aches and pains. But their ailments are not always so mild.

Saw Eh Say describes one appendicitis patient who came in four days before this interview.

Saw Eh Say: The man was so severe that we referred him to the Kawkareik Township Hospital, but on the way he passed away.

Jared Downing: That tragedy was more the fault of the narrow trails that link the village tract to the outside world than the clinic’s resources.

But Eh Say tell me about another patient, a woman with a severe uterine infection, who actually made it to the government hospital, to little avail.

According to Eh Say, the staff at the hospital grumbled, asking why the KDHW couldn’t care for its own patients, and were reluctant to process her.

Eh Say claims they gave her minimal treatment and refused to do more – even when the woman’s condition grew worse – unless she paid hefty fees.

In the end, they simply took her to the Mae Tao Clinic.

Eh Say: Previously the Kawkareik township medical officer said he will follow up with his staff to collaborate with my clinic and other health centres, but nobody obeyed him. I don’t know the reason why they don’t want to work with us.

Jared Downing: Eh Say is unwilling to speculate on the reason for the lack of cooperation. It doesn’t really matter, he said, because in the end it all comes down to money: Good treatment is rarely free, and rural Karen people can rarely afford it.

Thus, crossing into Thailand remains the default healthcare option.

One middle-aged man is visiting the clinic to get pain medication for his back. He tells me in his community nobody considers options other than Mae Tao when they break a bone or come down with dengue fever. The clinic is free, there are Karen-speaking staff and Mae Tao is only an hour further than the Kawkareik Township Hospital.

The Mae Tao Clinic has 140 beds and can refer cases to the 400-bed Thai public hospital in Mae Sot, which devotes almost half of its capacity to migrants, according to Mae Tao’s data. But the days of a single health centre shouldering the Karen burden may be numbered.

With democracy and tentative peace, the waves of battered refugees have ebbed – along with funding for humanitarian programs along the border.

Even though patient numbers at Mae Tao have remained steady, donor contributions have declined by as much as 70 percent, said Dr Cynthia Maung, who founded the clinic for fresh waves of refugees following the nationwide uprising in 1988.

Instead, donors are prioritising “development” projects inside Myanmar’s borders.

Dr Cynthia Maung: The population is growing and the ratio of health workers and doctors, nurses in Thailand or Burma, especially in the border area, has become a big challenge.

With dwindling healthcare resources on the Thai side of the border, Cynthia Maung said Mae Tao has had to increase referrals to hospitals in Myanmar. But matching, say, an HIV patient with a government hospital, communicating the specifics of their condition and treatment history to the staff, and ensuring that they continue to receive proper care can be a herculean task.

Cynthia Maung: The problem is that many young people are working in Thailand and moving back and forth. Thirty percent don’t have a national identity card.

Jared Downing: It is common for people from Kayin State to arrive at a hospital with no identification, or an ID document that is recognised by one of the KNU organisations but not the Myanmar government. Even the name of their township might not match up.

The area known as “Hpa-An” to the KNU, for example, also contains what the Myanmar government recognises as the Kawkareik, Myawaddy and Hlaingbwe townships.

Cynthia Maung: In the hospital you need referrals for continuity of care and quality of care. There is no consistency of care.

Jared Downing: She fears that until the various administrations can develop and merge their systems, a child with dengue fever, a farmer with a broken leg or a woman going into labour might find themselves languishing in a waiting room as the red tape is sorted.

Fortunately, some progress has been made in recent years, if mostly in meeting rooms rather than hospital wards.

KDHW recently opened its third medical staff training centre in government-controlled Kawkareik, and democracy and the subsequent ceasefire have allowed NGOs working in KNU territory – formerly holed up in Mae Sot offices – far greater levels of access.

Furthermore, most of the various Karen healthcare providers have at least agreed to operate under the same umbrella, there have been initial meetings with Myanmar’s Ministry of Health, and the KDHW has initial drafts a five-year healthcare plan that mirrors that of the Myanmar government.

Eventually, in an ideal world, the Ministry of Health and KDHW would have complimentary registration and referral systems, the ministry would send doctors to KDHW clinics, and the Myanmar government would provide some funding and resources.

KDHW director Saw Eh Kalu Shwe Oo, said it’s not just government that is needed.

Saw Eh Kalu Shwe Oo: “It is not only government money. It will also need donation money and international assistance money, so those [parties] need to look to the national health plan and also the federal Kayin State health plan.”

Yet the issue of funding remains a future bridge to be crossed. At the moment, the KDHW plan is mainly a statement of priorities and goals; anything more detailed and action-oriented would need both Ministry of Health accreditation and backing by the various organisations under the KDHW umbrella.

Some organisations, such as the Back Pack Health Worker Team, also have operations in neighbouring states, and are thus accountable to not only Karen, but also Mon or Shan groups for their policy decisions.

Furthermore, some Karen groups are simply less trusting of their former adversary of 70-years, fearing that the government will use healthcare cooperation as a way to chip away at their hard-earned sovereignty.

Even if they trust the Ministry of Health, Eh Kalu Shwe Oo explained, they may not trust the Tatmadaw, national parliament or other stakeholders.

As for Cynthia Maung, she does not mistrust the Myanmar government as much as the idea of aligning too closely with the Ministry of Health’s broad, nationwide plan.

She argued that the top-down approach diverts resources from the organisations and projects in the trenches, citing Mae Tao’s own ebbing resources but steady intake of patients.

Cynthia Maung: “Thailand is looking at a national health plan, and Burma is looking at a national health plan, but border health is a more regional approach. Sometimes the national health plan, coming from the top, it is not appropriate or relevant to local context.”

Eh Kalu Shwe Oo, at least, tends towards optimism, and he assures hesitant parties that the way forward is towards true federalism. He uses an analogy coined by KDHW director of policy Dr Phu Marta – that of a fabric of many coloured strands, together strong and effective, but each strand retaining its own identity and mindful of its unique needs.

Perhaps in five years or so Aye Cho and her family will start going to her local hospital. For now, she will keep crossing the river.

Win Zar Ni Aung: We hope you enjoyed this edition of Doh Athan.  

This programme was put together this week by Zar Ni and A Htet. 

Please stay tuned for next Wednesdays’ episode and visit the Doh Athan Facebook page.

The project to support human rights reporting is a partnership between Frontier Myanmar and Fondation Hirondelle, funded by the Embassy of the Netherlands in Myanmar. 

Thanks for listening.

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