Burma: a country's health in crisis, César Chelala , The Lancet. 1998. Volume 352, page 1230. The Lancet is a British medical journal.
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Since antigovernment uprisings
in Burma 10 years ago, the military junta has ruled with an iron fist, transforming a
country with a vibrant economy into one of the most backward and repressive countries in
Asia. Little is known about the effect that the regime's policies have had on the health
status of the population. But, economic deterioration and a leadership more interested in
keeping its privileges than in the welfare of its people seems to have had a substantial
impact on health, particularly of women and children. According to UNICEF, which has compiled some of the most complete health statistics in the country, the national infant mortality rate in 1996 was 105 per 1000 live births. This rate compares poorly to 33 in Vietnam, 31 in Thailand, and 11 in Malaysia. As in many other developing countries that lack potable water and sanitation, major causes of children's morbidity and mortality in Burma are intestinal and respiratory infections, malaria, malnutrition, and vaccine-preventable diseases. One million children are reportedly malnourished, 9-12% severely so. Children aged 1-3 years are thought to get only 71% of the recommended energy intake and 76% of the recommended protein intake. The high rate of babies with birthweight below 2500 g (estimated at 23ˇ5% in 1991) probably reflects the high incidence of malnutrition among pregnant women. Childhood vitamin and mineral deficiencies, particularly of iodine and vitamin A, are major public-health problems. About 28% of schoolchildren have goitres, and in some areas these rates are even higher. Goitre is increasingly found in marginal low-income areas in Rangoon. Iron-deficiency anaemia is found in 30-44% of children aged 6-16 years and in 60% of pregnant women (more than 700 000). Diarrhoeal diseases in children under 5 account for about 18% of all deaths, and are the second most important cause of death in children in that age group. Mortality rates increase sharply when diarrhoea occurs with malnutrition or with other diseases. Although the use of oral rehydration salts is the most adequate treatment for uncomplicated cases of diarrhoea, inappropriate drug treatment is still given in more than 60% of instances. Cholera outbreaks occur every year. First identified in Burma in 1994, a new serotype of Vibrio cholerae causes many cases in the non-immune population, so high fatality rates are seen. The Universal Child Immunisation (UCI) programme, which is done with UNICEF's support, reaches less than 60% of children nationwide, and an even lower proportion in some areas. Higher immunisation rates have been hindered by security concerns, transportation problems, lack of electricity, and shortage of health workers, especially in remote areas. Women in Burma face considerable health problems because of poor living conditions, inadequate health services, and lack of basic education. Health care is even more deficient in the ethnic minority regions, where constant relocations and heavy losses of men's lives have left women with the complete responsibility of raising their children. Maternal mortality rates are 580 per 100 000 live births, as compared to 80 for Malaysia and 10 for Singapore. Most maternal deaths result from induced abortions, largely conducted in secret and unsanitary conditions. Basic reproductive health care is currently provided only in select areas of the country. 17-22% of women use modern contraception, substantially lower than the goal of 30% set in 1997 by UNFPA (United Nations Fund for Population Activities) and the Ministry of Health. Women frequently resort to abortion to control family size. 14% of married women aged 15-49 years have had an abortion during their married lives. This rate is much higher in the major teaching hospitals in Rangoon and Mandalay where the abortion rate is 330-500 per 1000 live births. Infectious diseases, including tuberculosis and malaria, are widespread. Leprosy is still endemic. 35 000 patients have deformities due to leprosy, 20% of whom are children and 50% women or adolescent girls. In 1997, UNAIDS estimated that 440 000 people in the country--about 1% of the population--had HIV infection. 86 000 adults and children have already died, and 14 000 orphans exist because of AIDS. Rates among intravenous drug users are among the highest worldwide--74% in Rangoon, 84% in Mandalay and 91% in Myitkyina, capital of the Kachin State on the border with China. Burmese prostitutes, who are often forced to have unprotected sex, are also vulnerable. The prevalence of HIV is up to 26ˇ5% in urban prostitutes, much higher than that in Thai prostitutes. Some experts believe that the real figures are higher, and the threat of spread is particularly serious because of an almost complete lack of public knowledge about the disease, and the stigma attached to sexually transmitted diseases. AIDS is increasingly affecting the general population, including women and children. In a border town in Shan State in 1995, 6-10ˇ6% of pregnant women who registered at public Maternal and Child Health Center clinics were HIV-positive. Women are particularly vulnerable to HIV infection because of unprotected sexual relationships with infected male partners, and transfusion of infected blood after childbirth because of anaemia or poor antenatal care. In at least two states, no blood products are screened. In recent years, the military regime has changed its name and tried to improve its image--eagerly seeking foreign investment and tourism. But internal repression continues, and the economic situation and the health status of the population continue to deteriorate, and may worsen with the current financial crisis in southeast Asia. The only way to reverse the situation is for the government to prioritise the health and wellbeing of its people over its military build-up. As Nobel laureate Aung San Suu Kyi, head of the main opposition party and focus of the pro-democracy movement, has said: "There will not be any difference if the heart does not change." César Chelala
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