By any account, Burma is a beautiful, naturally rich country with a diverse ethnic history. It is also run by one of the most oppressive regimes in the world, the State Peace and Development Council, an 11-member group of military commanders. This junta, in power under different names since 1988, has been cited for countless human rights abuses. The SPDC (as its commonly known) also oversees a corrupt, inefficient economy. In spite of the country’s natural wealth, social-economic conditions continue to deteriorate, along with Burma’s schools and hospitals.
The end result is between 1.5 and 2 million Burmese of various ethnicities have been forced to scatter into Thailand. Nearly 300,000 people – mostly representatives of the Karen, Karenni and Mon ethnic groups – live in nine temporary displaced persons camps based along the border. Several hundred thousand members of the Shan ethnic group also reside in Thailand, mostly as illegal immigrants because the Thai government does not recognize them as refugees.
A tenuous life
Burma’s refugees maintain a tenuous status in Thailand. Their rights and protections are nearly non-existent, mostly because Thailand is not a signatory of the 1951 UN Convention regarding the status of refugees, meaning only those displaced from Burma’s conflict zones are permitted to receive humanitarian aid. Of course, Thailand’s government acknowledges the countless other Burmese refugees, but strictly restricts their movement. A report by Suzanne Belton and Cynthia Maung illustrate the lack of freedom of movement for refugees and migrants: “If a Burmese migrant has a work permit, they may travel and use [Thailand’s] universal health insurance scheme but the climate of fear and uncertainty can stop people travelling. Public transport must pass through many road blocks and checks and if passengers are discovered not to have the correct papers they are deported.”
For the Shans and other illegal immigrants, life can be even more difficult than life in camps. These migrants often lack access to basic needs: clean water, sanitation and shelter, as well as access to education and health care. For girls and young women, human trafficking is especially problematic, especially with an estimated 16 brothels doing business in Mae Sot, the largest border town. One report found young trafficked girls “face a wide range of abuse including sexual and other physical violence, debt bondage, exposure to HIV/AIDS, forced labour without payment and illegal confinement.”
Reproductive health education
An often poor, usually traumatized population means reproductive health is a constant issue. However, most people who grow up in Burma have very little sexual or reproductive health education. In fact, a 2007 study of 400 Burmese adolescents who now live in Thailand demonstrated this lack of sexual knowledge. The study, carried out by a local NGO called the Adolescent Reproductive Health Network in Mae Sot, found:
– More than one-third of adolescents interviewed have never learned about sex or sexual anatomy;
– Nearly 25 percent of those surveyed reported being sexually active, usually around the age of 18. However, ARHN interviewers believe girls may have underreported their sexual activity;
– More than half of those surveyed reported awareness of basic contraception practices – condoms, the pill, and injections – but were not aware of emergency contraceptive methods; and,
– Of those who reported having sex, only 23 percent used a male condom and only 9 percent used birth control regularly.
The report also found fundamental differences between the sexes when it comes to deciding on whether to use birth control. Nearly two-thirds of the women interviewed said they had the right to use birth control regardless of their husband’s opinion. However, only half the men interviewed agreed with that statement. Perhaps making matters worse, 55 percent of males agreed that sometimes a female partner deserves to be beaten. More than 36 percent of females also agreed with this.
After reviewing the ARHN report, Nancy Goldstein points out the importance of peer sexual education on the Thai-Burmese border in a piece for RH Reality Check.
ARHN owes its ability to connect with young Burmese migrants to its intrepid, fiercely dedicated young peer educators. Inside Burma, any kind of humanitarian work that creates health for people outside of the army is considered political and can get a worker arrested, beaten, or even killed. And Burmese culture itself remains both highly conservative and very private regarding sex and sexuality. Few if any parents in the camps would think it’s cool that their son or daughter works as a peer sex educator, and peer educators have to be cautious about what they teach and where. “Every time ARHN’s peers go out into the community to conduct workshops on sexual safety and health, distribute contraception, or collect survey information, they risk arrest, violence, deportation, and the displeasure of their families,” says Tarjina Hai, ARHN’s current technical advisor.
As one peer educator explained to me, a relatively easy, obstacle-free training session is one that has the blessing of the village leader and religious leader or pastor, and takes place in a church. It involves incredibly expensive travel, but only one or two illegal border crossings, and requires bribing only a handful of authorities. That’s if you’re lucky: if there are too many people around when the educator is stopped at the border, no bribery can take place, meaning that his or her half done and fully paid for trip ends there.
Yet the work must continue. As Leila Darabi has noted, Thailand’s fairly rigorous family planning program is not reaching these young Burmese migrants, who are at significant risk for unplanned pregnancy, sexual assault, and sexually transmitted diseases. Many of these youth are working and living in factories (some legally, most not). They don’t have ready access to contraception, and they’re easy prey for both transactional and coercive sex. Most refugees have scant access to any kind of health care at all, let alone sexual and reproductive health care. Education efforts are stymied by low literacy rates, limited access to television, and virtually no access to the Internet.
Mixing sexually active people without proper reproductive education, abortion often becomes an issue. The UNFPA estimates in Burma that nearly one-third of pregnancies end in abortion. However, by law, abortion can only take place when the mother’s life is at risk. Abortion is not so restricted in Thailand, which also allows it for proven cases of incest and rape. Regardless of the restrictions, however, abortions continue in the refugee community. The Thai health ministry believes the abortion rate for Burmese migrants is nearly two-and-a-half times higher than the rate for the local Thai population. Belton's and Maung's 2002 study of reproductive health outpatient care found:
– 25 percent of women with post-abortion complications underwent self-induced abortions like those common in Burma: drinking ginger and whiskey, vigorous pelvic pummeling and inserting sharp objects into sexual organs;
– Most of the women with post-abortion complications are married and two-thirds of them already have at least one child;
– One-third of the women have already had at least five pregnancies.
Here is a discussion regarding how the issue reproductive health for adolescents is intertwined with abortion on the Thai/Burma border with Cari Siestra, who helped edit the AHRN report.
The Mae Tao clinic
For Burma's refugees, the Mae Tao clinic has helped fill the massive health care gap. It was launched by Cynthia Maung who left Burma when 10,000 student activists fled across the border in September 1988 after the government violently cracked down on pro-democracy protests. Dr. Cynthia, as she’s called, thought it would only be a matter of weeks before she could return to her small Rangoon medical practice. Instead she became appalled by the lack of care at the makeshift refugee camps, where the refugees pouring across the border were suffering from trauma, from gunshot and landmine injuries, malaria and diarrhea. She opened a clinic in the Huay Kaloke camp with only her medical textbook and a rice cooker to clean and sterilize instruments.
Today, the Mae Tao clinic counts a staff of 5 physicians, 80 health care workers, 40 trainees and 40 support staff. This staff treats more than 100,000 patients annually. Two students at Westminster College who participated in a service learning project at the clinic provide a good description:
The floors were uneven cement, covered by mud. It is best described as an outdoor walk through clinic; each service had its own room. The waiting area was overly crowded with exhausted displaced Burmese people. When we walked past the pediatric center we saw immobile malnourished children being comforted by their parents.
The clinic provides service in a number of different areas, from baby vaccinations to creating prosthetics for injuries due to landmines. In 2006, doctors at the hospital delivered 1600 children. The clinic also provides trainings on maternal care. Cathy, who works at Mae Sot clinic, explains some of the issues surrounding the reproductive health trainings.
The Clinic runs an active birth control program, but not everyone has had the education. For migrant women (many thousands working in Thailand in the sweatshops, trying to help their family,) life is not easy. Most women need a protector of some sort. With a baby, it is impossible to continue working. Dr. Cynthia and the Karen Women’s Organization run several orphanages. The Karen has enormous charity for each other. I have not a met a more caring people. Generally, the husbands are with their wives as they have their babies and giving birth is a thing of great joy but often on the other side of the building there are women very sick as the result of botched back street abortions.