Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling.

BACKGROUND: Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions. METHODS: From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6-59 months and women aged 15-49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year. RESULTS: Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6). CONCLUSIONS: Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.

Community-based assessment of human rights in a complex humanitarian emergency: the Emergency Assistance Teams-Burma and Cyclone Nargis.

INTRODUCTION: Cyclone Nargis hit Burma on May 2, 2008, killing over 138,000 and affecting at least 2.4 million people. The Burmese military junta, the State Peace and Development Council (SPDC), initially blocked international aid to storm victims, forcing community-based organizations such as the Emergency Assistance Teams-Burma (EAT) to fill the void, helping with cyclone relief and long-term reconstruction. Recognizing the need for independent monitoring of the human rights situation in cyclone-affected areas, particularly given censorship over storm relief coverage, EAT initiated such documentation efforts. METHODS: A human rights investigation was conducted to document selected human rights abuses that had initially been reported to volunteers providing relief services in cyclone affected areas. Using participatory research methods and qualitative, semi-structured interviews, EAT volunteers collected 103 testimonies from August 2008 to June 2009; 42 from relief workers and 61 from storm survivors. RESULTS: One year after the storm, basic necessities such as food, potable water, and shelter remained insufficient for many, a situation exacerbated by lack of support to help rebuild livelihoods and worsening household debt. This precluded many survivors from being able to access healthcare services, which were inadequate even before Cyclone Nargis. Aid efforts continued to be met with government restrictions and harassment, and relief workers continued to face threats and fear of arrest. Abuses, including land confiscation and misappropriation of aid, were reported during reconstruction, and tight government control over communication and information exchange continued. CONCLUSIONS: Basic needs of many cyclone survivors in the Irrawaddy Delta remained unmet over a year following Cyclone Nargis. Official impediments to delivery of aid to storm survivors continued, including human rights abrogations experienced by civilians during reconstruction efforts. Such issues remain unaddressed in official assessments conducted in partnership with the SPDC. Private, community-based relief organizations like EAT are well positioned and able to independently assess human rights conditions in response to complex humanitarian emergencies such as Cyclone Nargis; efforts of this nature must be encouraged, particularly in settings where human rights abuses have been documented and censorship is widespread.

Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma.

BACKGROUND: Case reports of human rights violations have focused on individuals' experiences. Population-based quantification of associations between rights indicators and health outcomes is rare and has not been documented in eastern Burma. OBJECTIVE: We describe the association between mortality and morbidity and the household-level experience of human rights violations among internally displaced persons in eastern Burma. METHODS: Mobile health workers in conflict zones of eastern Burma conducted 1834 retrospective household surveys in 2004. Workers recorded data on vital events, mid-upper arm circumference of young children, malaria parasitaemia status of respondents and household experience of various human rights violations during the previous 12 months. RESULTS: Under-5 mortality was 218 (95% confidence interval 135 to 301) per 1000 live births. Almost one-third of households reported forced labour (32.6%). Forced displacement (8.9% of households) was associated with increased child mortality (odds ratio = 2.80), child malnutrition (odds ratio = 3.22) and landmine injury (odds ratio = 3.89). Theft or destruction of the food supply (reported by 25.2% of households) was associated with increased crude mortality (odds ratio = 1.58), malaria parasitaemia (odds ratio = 1.82), child malnutrition (odds ratio = 1.94) and landmine injury (odds ratio = 4.55). Multiple rights violations (14.4% of households) increased the risk of child (incidence rate ratio = 2.18) and crude (incidence rate ratio = 1.75) mortality and the odds of landmine injury (odds ratio = 19.8). Child mortality risk was increased more than fivefold (incidence rate ratio = 5.23) among families reporting three or more rights violations. CONCLUSIONS: Widespread human rights violations in conflict zones in eastern Burma are associated with significantly increased morbidity and mortality. Population-level associations can be quantified using standard epidemiological methods. This approach requires further validation and refinement elsewhere.

Prevalence of Plasmodium falciparum in active conflict areas of eastern Burma: a summary of cross-sectional data.

BACKGROUND: Burma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown. METHODS: Plasmodium falciparum (Pf) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf(R)). Pf prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate Pf prevalence by age, sex, and dry vs. rainy season. RESULTS: 9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 - 8.6; 2004: 7.1%, 95% CI: 6.9 - 7.3; 2005:10.5%, 95% CI: 9.3 - 11.8 and 2006: 9.3%, 95% CI: 8.2 - 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 - 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 - 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 - 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 - 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 - 8.8; to 12.4%, 95% CI: 9.4 - 15.4). CONCLUSION: Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.