The headlines on refugees from Myanmar (formerly known as Burma) grab attention - "Burmese abortions drain the medical budget", "Thailand has the worst HIV/AIDS epidemic in Asia", "Child prostitution is unsolvable" - but they don't tell the whole story. By the end of 1997, 215,000 Burmese refugees had sought refuge in Thailand, India, Bangladesh, Malaysia and China. An additional 350,000 Burmese live in "refugee-like" circumstances in Thailand without refugee status or protection, though most of them have fled due to a well-founded fear of persecution. The Thai government distinguishes between two different Burmese groups in Thailand. One group of people of primarily rural origin was in civil conflict with the Burmese government and began to cross over the border to Thailand in 1984; the other group is made up of Burmese of primarily urban origin who fled after the student-led pro-democracy uprising in 1988 and is often referred to as "students". The Mae Tao Clinic is one of the few providing reproductive and other health services to these refugees.

The Mae Tao Clinic

Dr Cynthia Maung - a Burmese physician who fled during the pro-democracy uprising in 1988, founded the Mae Tao Clinic in Mae Sot, Thailand, in 1989. The clinic responds to the health needs of Burmese refugees and displaced persons fleeing hostilities and persecution in Myanmar, and provides out-patient health services such as maternal and child health-care (including safe motherhood care and family planning), pharmacy and laboratory services. In-patient services include obstetrics and long-term care for chronically ill and terminal patients. Many of the clinic's 60 volunteer health workers and students also live at the clinic compound and are on-call 24-hours a day.

Although the Thai government has provided little support to the refugees, it has historically turned a blind eye to the clinic, which co-ordinates with the Mae Sot Hospital for complex and emergency referrals, vaccinations, contraceptives and laboratory testing. Recently, the Thai Public Health Service has shown greater interest in collaborating with the clinic to assist the Burmese population by providing land, water and sanitation improvements and increased collaborative efforts on community health outreach activities.

Reproductive health problems

Many young Burmese women lack reproductive health knowledge and contraceptive use is low. In addition to unwanted pregnancies, these young women are also particularly vulnerable to STIs and HIV infection. Underlying factors include sex for survival needs and the overall decline in the regional economic situation, exacerbated by powerful wealthy Thai and Burmese men involved in drug trafficking and sexual exploitation.

While the number of contraceptive acceptors has increased annually due to the Clinic's family planning education programme, the numbers of women and girls presenting to the Clinic with complications of abortion show that there is still a significant unmet need for family planning services. In 1999, 277 women presented to the clinic with complications of abortion. An alarming 23% were young women under 20 years of age and one out of five had had at least one previous abortion. It is not possible to get an accurate number of spontaneous versus induced abortions, as women are not forthcoming about induced abortions.

In response to these incidents of young women arriving at the Clinic with fever and infection after botched "at-home" abortions, the Clinic has stepped up family planning counselling for medics and the community, has improved post-abortion care services and has increased free condom distribution.

Building local capacity

Training is provided at the Clinic for its own health workers, as well as for health workers who work inside Myanmar (such as the mobile medical teams and backpack medics), health staff working with NGOs that manage refugee camps along the Thai/Burmese border, and traditional birth attendants (TBAs). The four main training programmes conducted through the Clinic focus on primary health-care, reproductive health, primary eye-care and laboratory management.

Backpack medics - The Backpack Health Worker Team Programme trains 50 teams of three medics to provide preventive and curative care and to educate local health workers in four main areas: reproductive health, primary health education, communicable diseases and landmines/war first aid. Training takes place in an annual 10-month training programme, followed by a two-year internship at the Mae Tao Clinic. The backpack medics' services cover about 100,000 internally displaced persons (IDPs) living in areas too remote or dangerous for clinics on the Thai-Burmese border.

The major reproductive and other health problems the backpack health workers face among the IDPs in Myanmar are obstetric emergencies and landmine injuries, with patients requiring blood transfusion. The emergency obstetric skills of medics working with IDPs in Myanmar are limited and safe blood transfusion services are not available. Patients are referred to Karen National Union (KNU) clinics in Myanmar, but HIV-testing is not available and blood type and cross-matching is very rudimentary. Known HIV-negative medics donate their own blood to save a life in an extreme emergency.

Traditional birth attendants - To reduce the risks of pregnancy-related death and disability, three senior medics at the clinic conduct a training course for TBAs, which trains them how to use clean delivery supplies and how to identify, manage and refer women who are suffering from complications of delivery. After the training, the TBAs are equipped with a kit of basic hygienic supplies. Mae Tao Clinic staff have also piloted a trainer-of-trainers programme for the backpack medics to train TBAs in remote areas of the Thai-Burmese border. One volunteer described this as "a wondrous sight – 15 older women, sitting in a circle in a bamboo hut, smoking pipes and sharing information about types of deliveries, clean techniques and traditional birthing practices".

External support

The Mae Tao Clinic receives support from individual and agency donors; volunteer health workers come from many countries, including foreign medical students who seek internships at the clinic. Funds are used for health education projects, an orphan care programme, special events and general operating expenses.

The Clinic also receives support from the Women's Commission for Refugee Women and Children to:

-integrate reproductive health into training programmes for all health workers;

• improve reproductive health education materials in order to increase the awareness of reproductive health, including HIV/STIs, among Burmese displaced people;
• provide "birthing kits" to trained health workers;
• empower women to seek help if they have been victims of violence through workshops on: women's community education and assertiveness training, women's rights, domestic violence, access to health-care services and leadership;
• conduct weekly seminars for medics to discuss cases and issues;
• improve the pharmacy, obstetric and gynaecology facilities and
• increase the Clinic's laboratory diagnostic capacity.

With this outside support, but especially by involving the local communities, the Mae Tao Clinic manages to provide Burmese refugees with quality reproductive health services under difficult circumstances.