Jan 2004

MYANMAR [BURMA] :: An Interview with Dr. Frank Smithuis - Country Manager + Medecins Sans Frontieres Medical coordinator

Why is Médecins Sans Frontières in Burma/Myanmar? Médecins Sans Frontières wants to work for the most vulnerable, disadvantaged groups in a country. In Myanmar we have so far selected 2 groups. The first group is the population in Rakhine State, particularly the Rakhine Muslims. They are in a very difficult situation. They don’t have citizenship, therefore they are not free to travel. The access to health services is less than in other areas in the country. So we have chosen to do a project for that population. It is mainly a Malaria project, we treat over 100.000 Malaria cases per year.

© MSF Dr. Frank Smithuis in Myanmar.

But we have also recently started some clinics for patients with sexually transmitted diseases and for people with HIV/Aids.

The second group are people with HIV/AIDS or people who are at great risk to get HIV. Therefore we have activities for the prevention and care of people with HIV/Aids. People with Aids are discriminated all over the world, in some countries more than in others. I think that people with Aids are in a difficult situation in this country. In this country the epidemic has been under-estimated , thinking that Burma would be protected by its culture. Recently the authorities recognized that there are more people with HIV/Aids than previously thought. Still not enough activities are being done for people with Aids, and they are sometimes excluded from certain treatments. That’s not official policy, but we have seen that for example in Shan State and in Kachin State. So we try to work for people with Aids, we try to improve acceptance for people with Aids and improve access to medical care.

In 2003 we initiated an Antiretroviral Treatment Program in this country together with the government health authorities.

We also work on prevention. There are two main groups that are on high risk, and that are people with sexually transmitted diseases and sex workers and intravenous drug users. Both, sex workers and drug users are illegal and they potentially face serious prison terms. So, these people are very reluctant to go to government services, because the same government defines them as illegal and could arrest them if they identify them as sex workers or drug users. So we try to provide health services for them in the private sector in our own clinics.

Does the government know about that?
Yes, they do. And in general they seem to be OK with it. Sometimes they are afraid of a bad press. But I believe that they realize that they don’t really have to worry for that. In fact, they already have a bad press as most international media criticizes them. And we use these clinics just to treat patients, so that could not harm them.

© Marco van Hal A critically sick boy is put on a drip. His father anxiously waits for the medicine to take effect.

What about the HIV-rate in this country? How high is it? Actually, we don’t know. There are no good data available about HIV prevalence in this country. The government has done some surveillance in about 30 towns in the country. They have taken some population groups – pregnant women, military recruits but also sex workers and drug users. From that you can calculate some rates. But I am not sure how good the quality of the sampling is and secondly these are urban areas and therefore maybe not representative for rural areas. So it is very difficult to get an estimation.

What would be your estimation?
The authorities have always said that it is around 20,000 to 25,000 cases in the country. Recently they have increased the estimate to 180,000. I am afraid that it is much higher. But I prefer not to emphasise about the numbers too much. Anyway, 100,000 is a big problem, one million is an even bigger problem, but it would both need quite similar action.

What about testing HIV?
Testing is possible in government clinics and in the private sector. Unfortunately it is not allowed for international Non-Government Organisations [NGOs] but I believe that the authorities will allow international NGOs to test soon. I’ve asked the minister for approval and he said that we will probably get it soon. But we don’t have it yet. So, for the moment we can take blood and send the blood, to the government laboratory, with a code number to assure confidentiality.

How is the health situation in general in Burma?
Health services are seriously under-funded. There is a budget of under five million US-Dollars for a population of 50 million. That can never be enough. So firstly it is underfunded by the government. And secondly the international donor community does not want to give funding for the health system in Myanmar as it does for example in Laos or Cambodia or in other comparable countries, and that is for political reasons. The West clearly is not in favour of the current government and therefore decided not to give substantial foreign aid to this country. So for the population it means that they are in a double difficult situation.

And Non-Profit Organisations? Do they support the Burmese population?
There are some organisations, but for a population of 50 million people there are maybe 20-30 international NGOs of whom five or so are doing something significant in health, compared to Laos where there are less than 5 million people and over a hundred organisations. According to 1999 figures, in Myanmar there was one US-Dollar per person per year given by overseas development aid, in Laos that was 65 US-Dollars per person per year, in Cambodia that was 45 US-Dollars per person per year, and here it is one. You can not do much with one.

Do you think that is justified?
I think this is unethical. It ignores the humanitarian need in this country. Many governments and organizations do not support the current government. But the population can not be held responsible for the government they have and therefore should also not be punished in the sense of being boycotted for humanitarian aid.

Does Médecins Sans Frontières have a problem getting enough money for the projects? Not really. Most of it we have always received from Médecins Sans Frontières - offices such as Holland, Germany, UK, Canada and Austria. That is the great advantage of being financially independent. Now the donor community is – after 10 years of ignoring this HIV epidemic – getting easier because they realize that HIV in Burma is a serious problem and that they have to do something, that you cannot wait your political agenda to be fulfilled. Whichever government is in charge of this country, HIV will be a serious problem.

© Laurence Hugues Mudon test paludisme Mudon, testing for malaria in a mobile clinic.

Thailand started the “100 per cent condom program” which got great results in a short time. Would something like that work here in Myanmar, too?
Actually, they have also initiated it here, but in a different way. The 100% condom program is meant as an incentive for sex workers to use condoms. You can carry on with your job, and you will not be arrested, as long as you use condoms. But recently we have seen an increase in arrests of sex workers, which is definitely not a good incentive to stimulate the use of condoms. What actually happens is that people will hide more, people are afraid to have condoms in their possession because people will recognize then that they are sex workers. People will not easily seek health services when they have STDs because that would also put attention to them. So I think it actually has the opposite effect. The weakness of the 100% condom use in Myanmar might be due to a different approach by the health authorities and the police. The latter want to control HIV by controlling or by putting sex workers in prison, but it has probably the opposite effect.

When I hear things like that, how freely can you really work in this country without compromising Médecins Sans Frontières principles?
We can work quite freely, actually. It can take a long time to get approval to work in a certain area, but after permission is granted, we can treat people with AIDS, we can treat sex workers, we can give health education, promote condoms etc. That does not mean that everything that is happening in this country is according to Médecins Sans Frontières principles.

Besides HIV, which are the other main health problems?
Linked to HIV is Tuberculosis because that is the most common disease linked to Aids. Also linked to that are Sexually Transmitted Diseases because they facilitate the spread of HIV. HIV-TB and STD is one block, the other block is Malaria. We have started Malaria programs about nine years ago. We have done quite some research. We have studied Chloroquine and Fansidar, which were the drugs that were used previously. We found very high rates (65-85%) of resistance. Even Unicef and WHO were using / supplying these drugs, and continued to supply these drugs after we had given them the study results.

After the study we proposed to change the protocol which we were allowed to do after some hesitation of the authorities. And after several years, the government has now changed the protocol as well. It is now an Artesiminin-Mefloquin which is highly effective.

© Laurence Hugues Patients visit the MSF clinic in Mudon.

What are your biggest successes? Is there something like successes? I think there are several successes. For one is the malaria program. In the country we treat probably 150,000 Malaria patients per year, 100,000 of them in Rakhine state. I think that is significant. We give treatment that is about 95 to 100 % successful. We have done research that has contributed to the change of the national policy, and we are still doing research for cheaper medicines with fewer side effects.

I think that is one success. The second success is more difficult to measure. It is on the treatment of STDs and Aids. In the beginning it was very taboo, it was very difficult to work with high-risk groups, it was difficult to get treatment done for people with HIV/Aids. That has changed. It is absolutely not perfect, but we have set up health service for sex workers who come regularly. We have seen that in some areas there is a serious decrease in e.g. Gonorrhoea. In a Jade mine area where we have several clinics, the amount of Gonorrhoea is decreased so much that when I wanted to make a little study about drug sensitivity of Gonorrhoea, I did not find enough patients anymore. I like to believe that the thousands of patients we have treated for STD’s and the hundreds of thousands of condoms we have distributed, have contributed to this.

We have also worked on the desensitisation of the use of condoms. We have had large-scale poster campaigns, where we have posted several hundred thousand posters in addition to health education discussions. Last year we have given health education to people, discussions that last between thirty minutes and one hour to a total of one million people. I think this helps to desensitise preventive measures and to accept people with Aids.

We started home-based care for severely ill who cannot come to the clinic. In the beginning I was very worried how to keep the disease confidential for the neighbourhood. Well, I can assure you now, you can’t keep AIDS confidential in a home-based care program. Everybody knows within one minute that the person has AIDS and that you come for him because he has AIDS. But actually what it also did, because we shake his/her hand, we do a physical exam, we touch him, we put the stethoscope on him, we look in his throat etc., it actually made the people in the house and in the surrounding houses less fearful for people with AIDS, so actually I think it contributed to more acceptance for persons with AIDS.

We started an ARV treatment program with the government, which I believe has sped up ARV treatment in Myanmar. Next week we have a meeting with the Department of Health, how ARV treatment can rapidly expand in the country.

So you mean the government will do Anti Retroviral Treatment? Yes, because recently the Global Fund has agreed to give money for HIV/Aids in Myanmar, so if that money comes through - it is not sure yet because there might be several conditions on this money - if that money comes true, then I think that the government will implement some of that money for ARV-treatment. Where does the medicine come from? India has two big companies. They have offices established in Rangoon and they are in the process of getting these treatments approved for this country. And Thailand is also considering donating ARV treatment.

© Olivier Bonnet Malaria control and treatment in the MSF-CH clinic. The waiting room is quickly filled, while people are waiting they get information on how to protect themselves from malaria.

And you think they will really do it?
Yes, they will do it. Maybe slower than one would like to, because we have seen already many people who died of Aids, but things are changing. The government is opening up. It is still a long way to go but when I look at nine years ago, the word HIV was almost a kind of secret. The government has in the meantime put Aids as the number three priority after Malaria and Tuberculosis, so things are happening. Too little, too slow but things are happening.

Your challenges for the future?
To speed things up. Every country has to go through a process, first you ignore that you have a problem and then you come with some ineffective or even counter-productive solutions, like put them all on an island or let’s test everybody by force or arrest all the sex workers etc.etc. But finally there comes realization that this all doesn’t work. That we have to start offering condoms and sexual health services to sex workers instead of arrest and repression, we should promote voluntary testing instead of forced testing, and start caring for and treating people with AIDS instead of isolating and discriminating them. Sometimes this process is terribly slow. Therefore it can cost the lives of hundreds of thousands of people. So to speed up that process is definitely challenge number one.

So patience is the most important thing here?
No, impatience is the most important thing. To keep things and people moving.

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