Transnational and cross-border health care

Sufferers of human rights abuses, such as tortured political prisoners or land-mine victims, pour illegally across the nation’s borders, most often into Thailand. The third of these broader issues, then, concerns the dual nature of aid provision to Burma: a recent significant increase in in-country aid as well as competing funding regimes for the provision of cross-border and transnational health care.

In the civil war areas of eastern Burma, Neumann and Bodeker (2008) describe a revitalisation of traditional Karen medical knowledge and practices, in part because of acute shortages of pharmaceuticals and biomedicine. Their work has documented how Buddhist monks provide spiritual and mental health care and explores the ways in which traditional healers are working to fill healthcare gaps in the region. The Wa also depend in large part on traditional health practices and Magnus Fiskesjö (2008) has written of how this corpus of knowledge and practice has fared in its encounter with modern medicine, as well as how it has been disrupted significantly by forced relocations and the detrimental impact on the capacity of the Wa to build on their own traditions and to access adequate health care. These studies are significant because of the difficulty of conducting scholarship on health issues outside central Burma.

The provision of emergency health care and infectious-disease prevention programs exists outside Burma’s formal healthcare system. Cynthia Maung and the Back Pack Health Worker Team (BPHWT) and researchers such as Naing (2008) and Suzanne Belton (2008) cover the provision of aid within war zones, the HIV/AIDS epidemic in Burma and Thailand and emergency care for reproductive health issues in refugee populations. Maung and the BPHWT have described a dire healthcare situation in eastern Burma, where long-term, low-intensity conflict has given rise to a state of ‘chronic emergency’ (see Mahn Mahn’s chapter in this volume). Their work shows how, in some parts of Burma, major public health issues arise as a direct result of civil conflict and widespread human rights abuses perpetrated by armed groups. Forced displacement, forced labour and the destruction of food supplies are only a few of the human rights violations that have a significant impact on health in this region. Belton’s work has been located around the Thai–Burma border refugee camps, where Karen and other Burmese refugees encounter particular reproductive-health needs and challenges. The Mae Tao Clinic in Mae Sot works to identify and address these, providing important treatment, education and supplies to thousands of Burmese patients. Naing has analysed the HIV/AIDS epidemic affecting many Burmese migrant fishermen in Thailand, with an interest in developing effective prevention programs among those at risk. Other programs exist in neighbouring countries to aid Burmese working in the sex industry, victims of human trafficking and those who are affected by the 2004 tsunami—most particularly illegal migrants in and around Phuket in Thailand.

The failure of the State to provide accessible health care means that the roles of globalisation and transnationalism cannot be understated in the provision of emergency and preventive health care as well as the availability of medicines. The flow of illegal, unregulated medicines, some requiring cold-chain facilities and injectable vaccines containing attenuated viruses, is directed into Burma from all of its neighbours. In the modern pharmacies of Mongla in Wa State, for example, medical products from multinational companies such as Johnson and Johnson with Chinese script are available (Skidmore and Nordstom forthcoming). In the markets of Yangon, skin-whitening creams from India are sold beside heart medication from Thailand and psychiatric medications such as chlorpromazine and lithium manufactured in China (Skidmore 1998).[15]

Mongla is only one border town on the centuries-old southern Silk Route with significant numbers of Burmese people crossing the border on a daily basis. Burmese people similarly cross into the Indian state of Manipur through the Burmese border town of Tamu, and into Thailand via a series of busy border crossings. Medicines and illegal drugs and pharmaceuticals are carried across the region through these old trading routes (Skidmore and Nordstrom forthcoming). The help-seeking patterns of Burmese who live in proximity to border crossings thus contain more options than those living in the nation’s central river valleys.

[15] A survey of family-run businesses in Thein-byu Ze, one of Yangon’s main markets, shows that importers of raw materials for indigenous Burmese medicines source their products from more than 20 different countries (Skidmore 2003, unpublished field notes). Iran, for example, is only one of the many countries with which Burmese merchants have long-established trading relationships. Indigenous Burmese medicine is sent to what is commonly called the ‘border line’, meaning the official land exit points from Burma. These are mainly on the Chinese and Thai borders. Traders in border towns such as Tachilek then send the indigenous medicines around the world. In these efforts, Burmese traditional-medicine manufacturers and exporters are eagerly supported by the military regime. The pinnacle of such support occurred during the ascendency of the former Prime Minister, General Khin Nyunt, who was the patron and chair of the Traditional Medicine Council and who realised the multimillion-dollar industries in traditional medicine that existed in neighbouring China and India.