Myanmar, also known as Burma, has the unfortunate distinction of being home to the world’s longest-running civil war. For over sixty years, the Myanma military and various ethic groups have fought along Myanmar’s border, leading to countless lives lost and the utter destruction of surrounding areas. The continued strife has played a large part in exacerbating an already dire public health situation: When the World Health Organization compiled a ranking of global health systems in 2000, Myanmar came in 190th, second to last in a list of 191 countries.
The situation has slowly improved, especially with Myanmar opening itself up to democratic reforms, but Myanmar still has the highest child and infant mortality rate among ASEAN countries. According to UNICEF, about 56,000 children die in Myanmar each year before reaching the age of five. Around 50% of these deaths are caused by diarrhea, respiratory infections, and malaria, made worse by malnutrition. Myanmar also has one of the highest maternal mortality rates in Asia, at 200 deaths per 100,000 live births.
Under threat of violence and suppression, it takes a lot of grit and compassion to want to stage medical interventions in a conflict zone like Myanmar. But Community Partners International (CPI), a Berkeley-based nonprofit, has been doing so since 1998.
CPI’s work is based on a “train the trainers” model that combines the expertise of modern, evidence-based health interventions with the local reach and know-how of community-based partners. CPI’s Public Health Institute, for instance, developed a junior-college level curriculum that’s trained dozens of health program leaders, who will in turn provide training for the hundreds of health workers who provide both health services and train more lay villagers to give basic care. Similarly, the Mobile Obstetric Maternal Health Workers (MOM Project) has been essential in bringing high quality maternal healthcare directly to mothers.
Dr. Tom Lee, a co-founder of CPI, shared with us a few of the lessons CPI has learned about establishing a health network in turbulent areas:
Lesson 1) Innovate and adapt, always
One of the most challenging aspects of carrying out health or medical interventions in conflict areas is the lack of infrastructure. “Most of your essential services, especially for pregnant women, have historically been based in health facilities. Women go to centers for prenatal care, essential reproductive health services, emergency deliveries, treatable infections, etc. These facilities cannot be built or maintained in conflict areas because they’re often destroyed,” Dr. Lee explained.
The lack of infrastructure means you have to innovate and be conscious of your surroundings. “It doesn’t matter if it’s as simple as a pill or an injection — any medical or public health intervention that we implement has to be adapted to whatever the local context is,” Dr. Lee said. “A good example is our vaccination program: There’s no electricity and no roads where our local partners work, so we developed a network of small, solar-powered, energy-efficient refrigerators that can be carried on foot. Developing that whole system was all heavily influenced by the local context.”
Lesson 2) Be prepared to learn from the local community
Local people know their needs best – this is getting to be axiomatic in the world of international development. Dr. Lee shared an anecdote of how important it is to learn from local communities if you want your interventions to succeed: “Sandy Pyne, our CEO, loves to tell this story of a time she visited some villages to talk to midwives and see what they needed. She discussed prenatal care and obstetric care and other medical things, but one of the midwives raised her hand and said, ‘Actually, I’d like a bicycle.’”
Why? Because a lot of times, the people coming to CPI trainings were working in remote areas with widely dispersed populations. For some, it might even take them weeks of walking just to get to the trainings. Once equipped with knowledge, they needed an actual way of getting to the patients.
“If you don’t ask the question about what they need, you’re not going to find out what is,” Dr. Lee said.
Lesson 3) Health can heal in more ways than one
CPI has many plans for the future, but one thing CPI finds itself increasingly engaging in is the country’s reconciliation process. The government is one of the largest stake holders in public health, after all, so after years of working off the radar, CPI officially registered with the government and has been cultivating a strong relationship with the Ministry of Health ever since. Meanwhile, their work along borders has helped them develop harmonious ties to border organizations in areas controlled by non-state actors or resistance groups.
“We’re trying to bring these two groups together to build bridges and push reconciliation,” Dr. Lee commented. “This war has changed the lives of two or three generations of people. It’s going to take a long time for those rifts to heal, so health is a convenient way to build trust, because health affects everyone.”
One thing they are working on now is a joint malaria-control campaign. CPI signed an agreement with the government last year, bringing groups in the central areas and groups in borders area to work together under the CPI umbrella. This involves agreeing to do what might have been considered sensitive in the past, like sharing data on where health posts and clinics are located.
“You can imagine that for the border partners, in the past they would never have wanted to share information about where they were located because they would be burned down. Now they have to be willing to share information and accept visitors or monitors from the Ministry of Health,” Dr. Lee said.
On the flip side, concessions have to come from the government’s end as well. In times of conflict, the “resistance areas” often develop their own health networks of hundreds or even thousands of community health workers.
“When peace happens, you don’t want that whole system to be brushed aside,” Dr. Lee explained. “You can imagine the government could choose to send in government health workers or big international nongovernmental organizations, but instead of shutting down the local health system that is already very effective and built up over many years, we work with the government to encourage them to recognize and give accreditation to allow those systems and health organizations to continue working. We push each side to compromise and that helps bring them closer together.”
Local communities have a strong thirst for knowledge, and empowering them to help one another can lead to a healthier, more peaceful country.