This new report from Johns Hopkins and UC Berkeley weighs in at 5 Mb. If your internet connection can handle it you can find it at http://www.hrcberkeley.org/download/BurmaReport2007.pdf
The [him] moderator has extracted a text version of the executive summary below for your reading convenience.

The report uses the well trodden method of human rights reporting by “naming and blaming” poor governance by the junta in Myanmar as something that needs to change. Most of the recommendations are directed at the government. They will be ignored.

But the [him] moderator has seen that the field of the ‘right to health’ has in the last few years developed well beyond ‘naming and blaming’. He would like the human rights centres at UC Berkeley and Johns Hopkins to support the development of human rights based programming and other activities that they suggest are necessary for effective and equitable service delivery inside Burma/Myanmar:

“Capacity-building of organizations dedicated to health care delivery involves many fundamental activities ... but at its core must be the development of an organizational culture that upholds medical ethics and human rights. This entails (1) applying a human rights framework to the design, implementation, and monitoring and evaluation of programmatic activities; (2) actively promoting the participation of affected communities in program development and implementation; (3) carrying out policies and programs in a nondiscriminatory manner; (4) maintaining transparency on how priorities are set and decisions made; (5) upholding accountability for the results.

[him] moderator

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Executive Summary
Decades of repressive military rule, civil war, corruption, bad governance, isolation, and
widespread violations of human rights and international humanitarian law have rendered
Burma’s1 health care system incapable of responding effectively to endemic and emerging
infectious diseases.2 Burma’s major infectious diseases—malaria, HIV/AIDS, and tuberculosis
(TB)—are severe health problems in many areas of the country. Malaria is the most common
cause of morbidity and mortality due to infectious disease in Burma. Eighty-nine percent of the
estimated population of 52 million lived in malarial risk areas in 1994, with about 80 percent of
reported infections due to Plasmodium falciparum, the most dangerous form of the disease.3
Burma has one of the highest TB rates in the world, with nearly 97,000 new cases detected each
year.4 Drug resistance to both TB and malaria is rising, as is the broad availability of counterfeit
antimalarial drugs. In June 2007, a TB clinic operated by Médecins Sans Frontières–France in
the Thai border town of Mae Sot reported it had confirmed two cases of extensively drugresistant
TB in Burmese migrants who had previously received treatment in Burma. Meanwhile,
HIV/AIDS, once contained to high-risk groups in Burma, has spread to the general population,
which is defined as a prevalence of 1 percent among reproductive-age adults.5
Meanwhile, the Burmese government spends less than 3 percent of national expenditures on
health, while the military, with a standing army of over 400,000 troops, consumes 40 percent.6
By comparison, many of Burma’s neighbors spend considerably more on health: Thailand
(6.1%7), China (5.6 %8), India (6.1%9), Laos (3.2%10), Bangladesh (3.4%11), and Cambodia
(12%12).
In response to the Burmese government’s chronic neglect to care for the health of its citizens,
UN agencies and international aid organizations began arriving in Rangoon in the 1990s. Under
the watchful eye of the military authorities, they launched programs aimed at lessening the
burden of infectious diseases, and by 2004, 41 aid organizations were operating in Burma with a
total budget of approximately $30 million. That same year, the Global Fund to Fight AIDS,
Tuberculosis, and Malaria (Global Fund) signed a contract with the United Nations Development
Programme (UNDP) to disperse $98.4 million over a five-year period to combat infectious
diseases in Burma.
But in August 2005 the Global Fund terminated the contract, explaining that new travel
restrictions imposed by the Burmese government had severely limited the ability of the UNDP
and its implementing partners to access project sites. Four months later, Médecins Sans
Frontières–France (MSF) announced it was pulling out of Burma for similar reasons, and the
International Committee of the Red Cross (ICRC) said it had suspended visits by its medical
staff to prisons because the Burmese authorities had insisted that ICRC doctors be accompanied
by members of the Union Solidarity and Development Association (USDA), a junta-backed
social organization with direct ties to military leaders, including Senior General Than Shwe. In
February 2006, the Burmese government issued guidelines to international organizations
formalizing the kinds of travel restrictions that had led to the departure of the Global Fund and
MSF–France.
To fill the breach left by the Global Fund’s withdrawal, the European Union, along with
Australia, Britain, the Netherlands, Norway, and Sweden, launched the “Three Diseases Fund,”
or 3D Fund, in October 2006. The fund, worth $99.5 million over five years, aims to bypass the
central government to provide aid to UN agencies, international and local nongovernmental
organizations, and “civilian administrations” to fight infectious diseases in Burma. The 3D Fund
will “target those most at risk of being infected by each of the three diseases, with a particular
focus on those who have limited or no access to public health services due to geographical or
security considerations, or for reasons of ethnicity, gender, stigmatization or financial status.”13
The 3D Fund has stated that its resources will “be used effectively, efficiently, transparently,
accountably and equitably … with an emphasis on achievement of programme outputs.”14
Against this background, our two centers—Human Rights Center, University of California,
Berkley and the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of
Public Health—launched a research project in July 2006 to understand the factors that have
contributed to Burma’s dire health situation and to the spread of infectious diseases in Burma and
across its borders. We also wanted to see if it was possible to deliver international aid to combat
infectious diseases in Burma in a manner that would be transparent and accountable, reach those
most in need, and promote respect for human rights and international humanitarian law.
We began our research by dispatching teams of researchers to Rangoon and the border regions of
China, Thailand, Bangladesh, and India. During these missions, researchers gathered data about
infectious diseases—primarily HIV/AIDS, tuberculosis, malaria, and lymphatic filariasis—from
health clinics operated by local governments and nongovernmental organizations. The teams also
interviewed health professionals, government officials, and representatives of nongovernmental
and community-based organizations that operate preventative programs and provide therapeutic
care to patients. After the initial trip, researchers made repeat visits to Burma and the border
regions of Thailand and India to collect further information. In addition, one of our researchers
interviewed staff members of the Global Fund in Geneva and representatives of the European
Union in Bangkok charged with drafting the strategic plan for the 3D Fund. All interviews were
conducted in accordance with procedures established by the Office for the Protection of Human
Subjects of the University of California, Berke

ley and Johns Hopkins University.15
This report is premised on four precepts related to health and human rights (see “Introduction”).
First, successful public health infrastructures, programs, and outcomes are usually a result of
good governance and a respect for human rights. Second, respect for human rights and
international humanitarian law helps to ensure accountability, transparency, responsible use of
health expenditures, and rapid and equitable delivery of relief in areas of armed conflict.
Inversely, serious violations of human rights and international humanitarian law that affect the
movement of large population groups can cause or exacerbate the spread of infectious diseases.
This is particularly true among migrant or internally displaced populations who generally lack
access to appropriate health services. Third, as the World Health Organization (WHO) affirmed
in 2001, public health interventions for vulnerable groups are most effective if they also succeed
in respecting, protecting, and fulfilling the rights of people marginalized by society.16 Finally,
donors and nongovernmental organizations working in the health sector, especially in countries
with highly repressive regimes, have a responsibility to respect and promote the human rights of
those they serve.
We offer the following conclusions and recommendations:
Health Care System in Burma
• The Government of Burma must develop a national health care system that is
participatory and incorporates human rights so as to ensure that health care is
distributed effectively, equitably, and transparently. Promoting participation as a feature
of health system reform is now commonplace. With the rise of Primary Health Care in
the 1970s, community involvement was seen as an essential ingredient of a nation’s
health improvement. More recently, the emphasis has shifted to stakeholder consultation
in sector reform. With the rise of rights-based approaches, emphasis is increasingly being
placed on the participation of service users not as “beneficiaries” or “consumers” but as
citizens who have the right to have a say in shaping health care policies. Community
participation in the promotion and implementation of prevention and treatment programs
is essential in any campaign to combat infectious diseases.
Burma must develop a health care system that provides medical treatment and
preventative care to all citizens, especially the most marginalized members of society
including the very poor, ethnic and religious minorities, refugees and the displaced,
persons living in conflict and cease-fire zones, and persons belonging to socially
stigmatized groups including commercial sex workers, injecting drug users, and men who
have sex with men.
• The Government of Burma should increase its expenditures in health and education.
Decades of neglect by Burma’s military government have turned the country into an
incubator of infectious diseases. Those of gravest concern are HIV/AIDS, tuberculosis,
malaria, acute respiratory infections, filariasis, and diarrheal diseases. The authorities
have a responsibility to protect the people of Burma and residents of neighboring
countries to turn back the spread of communicable diseases. Such an effort requires both
public health measures and providing citizens with increased access to both formal and
informal education. Schools are places not only for teaching traditional academic
subjects, but also for disseminating information about measures that can be taken to halt
the spread of infectious diseases. Military expenditures should be reallocated to support
health and education. Burma is not at war with its neighbors, and its security is more
profoundly threatened by the rise of drug-resistant malaria and tuberculosis, and
emerging communicable diseases such as avian influenza and recrudescent polio
myelitis, than from external military threats.
Donors and International Aid Organizations
• Donors and international aid organizations operating in Burma have a duty to uphold
and promote internationally accepted standards of human rights and international
humanitarian law. Donors and international aid organizations should put into practice
the “Principles for Good International Engagement in Fragile States & Situations” drafted
by the Organisation for Economic Co-operation and Development (OECD) in 2005.
Principle 6 states: “Real or perceived discrimination is associated with fragility and
conflict, and leads to service delivery failures. International interventions in fragile
states17 should consistently promote gender equality, social inclusion and human rights.
These are important elements that underpin the relationship between state and citizen,
and form part of long-term strategies to prevent fragility. Measures to promote the voice
and participation of women, youth, minorities and other excluded groups should be
included in state-building and service delivery strategies from the onset.”18
• The Government of Burma should immediately rescind the “Guidelines for UN
Agencies, International Organizations and NGOs/INGOs on Cooperation Programme in
Myanmar” (See Appendix). These Guidelines, issued by the Ministry of National Planning
and Economic Development in February 2006, directly contravene several formal
agreements established between international organizations and the Burmese government
since the early 1990s. They also contravene several international agreements on effective
aid delivery, including the Paris Declaration on Aid Effectiveness, which was endorsed by
the European Union, 27 regional and international institutions, including the World Bank
and the Asian Development Bank, and over 90 countries in Paris in 2005. The Guidelines
have restricted the work of international organizations, especially ICRC, operating in
Burma. While aid to Burma should not be considered optional given the dire need, the
“exigencies of need” should never override the ability of organizations to access project
sites on a regular and unhindered basis to ensure that aid is being delivered in a manner that
is transparent, accountable, efficient, and equitable. The Guidelines are antithetical to this
fundamental principle.
• The Government of Burma should allow the International Committee of the Red Cross
(ICRC) to resume visits to prisoners without the requirement that ICRC doctors be
accompanied by members of the Union Solidarity and Development Association
(USDA) or other organizations. As mandated by the Geneva Conventions, to which
Burma has been a party since 1992, the ICRC conducts confidential, one-on-one visits
with prisoners and has done so in dozens of countries since the Franco-Prussian war
of 1870. In addition, the Government of Burma should allow ICRC to reopen field
offices that have been closed since late 2006 due to government restrictions. Since
1999, ICRC has played an essential role by visiting and providing health care to prisoners
in Burma and developing water and sanitation projects in war-torn communities where
weakened infrastructure, isolation, and the security situation make the population
particularly vulnerable.19 ICRC staff have convened surgical training seminars for scores
of Burmese health workers stationed in conflict areas, built water and sanitation facilities
reaching more than 70,000 beneficiaries, provided over 7,000 landmine victims and other
physically disabled people with prosthetic services, and supported the local manufacture
of 19,600 prostheses. Between 1999 and late 2005, ICRC made 453 visits to dozens of
prisons and labor camps throughout the country and provided training to Burmese doctors
on prison health care. ICRC has used inform

ation gleaned from these visits to persuade
health authorities to improve prison conditions. Yet, due to government restrictions,
ICRC has been forced to suspend its prison visits and close most of its field offices.
• Donors and foreign aid organizations should monitor and evaluate how international
aid to combat infectious diseases in Burma is affecting domestic expenditures on
health and education. Large infusions of foreign aid directed at the health sector can
potentially lessen the burden of infectious diseases in Burma, but it can also have
unintended consequences. Foreign aid can create dependency and divert health
professionals and their institutions from addressing other serious health problems.
Foreign aid can provide national authorities with a ready excuse for decreasing even
further their already paltry expenditures in health. Donors and foreign aid organizations
have a responsibility to monitor domestic expenditures in health and education and, if
problems arise, raise their concerns with the appropriate authorities.
Drugs and Drug Trafficking
• Relevant UN agencies, national and local governments, and international and local
NGOs should establish a regional Narcotics Working Group. Since 1999 the Burmese
government and the UN Office on Drugs and Crime (UNODC) have been engaged in an
aggressive campaign to eradicate poppy cultivation and heroin production in Burma.
UNODC has attempted to develop crop-replacement initiatives for poppy farmers.
However, these initiatives have often faltered, leaving farmers and their families with few
alternatives to feed their families. Tens of thousands of people have been forcibly
relocated to villages along the Thai border where they have no sustainable income and
are exposed to infectious diseases, especially malaria. At the same time, the region is
experiencing a significant increase in the production and use of methamphetamines. At
least three cease-fire organizations in Burma continue to manufacture and sell
methamphetamines inside the country and across the border. Methamphetamine use
increases sexual risk-taking and greater exposure to communicable diseases, including
HIV/AIDS. Markedly increased rates of sexually transmitted infections have been found
in northern Thai women who use methamphetamines. Finally, large profits from the sale
of methamphetamines are fueling the “Casino Economy” along Burma’s border with
China. These casinos and other entertainment venues are magnets for prostitution and
trafficking of Burmese women and girls.
Given this situation, the Narcotics Working Group should develop a sophisticated list of
indicators to measure the use and trafficking of drugs in the region. Distinct from
traditional indicators, these indicators would capture detailed information about types of
drug, how much is being used, and by whom. Access to hard-to-reach populations and
regions would require fieldwork and cross-border approaches that value trust-building
and cultural appropriateness. The working group could also monitor the human and
environmental impact of poppy eradication programs and their effects on farmers and
their families.
Three Diseases Fund
• The Three Diseases Fund (3D Fund) should play an active role in promoting the
growth and capacity of local nongovernmental and community-based health
organizations to respond to infectious diseases in Burma and the border regions. Only
a few local nongovernmental and community-based organizations operate in the health
sector in Burma. Yet these organizations could potentially play a key role in the effort to
lessen the burden of communicable diseases in the region. These groups are well situated
to provide the community services required for the implementation of treatment and
prevention programs. They can also work in areas that may be inaccessible to UN
agencies and international organizations.
The 3D Fund, which is now the largest aid donor to combat infectious diseases in Burma,
deserves good marks for establishing an oversight board that includes independent
experts and for posting regular updates and reports of quarterly meetings of its board on
its web site. Yet the 3D Fund faces several challenges that must be overcome to conduct
its work effectively. First and foremost, it must contend with the military regime’s
restrictions on the travel of foreign aid organizations. ICRC’s closure of several field
offices operating in or near combat zones suggests that access to these areas will continue
to be heavily restricted and prevent aid from reaching those most in need. Second, while
the 3D Fund’s commitment to bypass the central government and fund civilian
administrations and local nongovernmental organizations at the state and township level
is admirable, it may be difficult to implement. The term “civilian administrations” is a
highly ambiguous concept in Burma, especially in rural areas where the military and
police hold unquestioned authority and influence.20 This situation has been further
complicated by reports that the Burmese authorities are establishing government-run
“coordination committees” at the district and township level to coordinate with the 3D
Fund and other relief efforts. According to the February 2006 Guidelines, members of
these new coordination committees would be drawn from junta-backed social
organizations such as the USDA, founded by junta leader Senior General Than Shwe.21
The involvement of representatives of these organizations could easily politicize and
complicate the dispersal of funds at the district and township level. To overcome these
obstacles, donors to the 3D Fund must be prepared to withhold funds until proper
conditions prevail.
Such challenges notwithstanding, the 3D Fund’s pledge to ensure its programs are
accountable, transparent, equitable, and reach those most in need is highly commendable
and deserves the support of governments and international health institutions.
Violations of Human Rights and International Humanitarian Law
• The Government of Burma must stop engaging in violations of human rights and
international humanitarian law and must hold accountable government and military
officials who are responsible for these abuses. Burma’s policies of forcibly relocating
civilian populations and requiring them to engage in forced labor have caused widespread
migration, food insecurity, disruption in livelihoods, and lack of access to regular medical
care. In conflict zones, the Burmese military is committing violations of the laws of war
including intentional and wanton destruction of civilian homes and food supplies; killing,
sexually assaulting, and torturing civilians; destroying medical supplies intended for
civilian populations; and arresting, detaining, and killing medical workers. These abuses
have left civilians, particularly young children, vulnerable to death and illness from
malnutrition, malaria, TB, night blindness (vitamin A deficiency), and diarrheal diseases.
In the first six months of 2007, the Burmese authorities detained over a dozen HIV/AIDS
activists, most of whom have since been released. Of particular concern is Phyu Phyu
Thin, a National League for Democracy youth member and a leader in the group’s
HIV/AIDS section, who was arrested on May 21, 2007, by authorities from the Ministry
of Home Affairs and the Police Special Branch. According to relatives, she has since
disappeared. Since 2002, Phyu Phyu Thin and her group have provided hundreds of
HIV/AIDS patients with counseling, medicines, education, and housing.22
Internally Displaced Persons, Refugees, and Migrants
• The Governments of Burma, India, Thailand, and Bangladesh should ratify the
C

onvention Relating to the Status of Refugees and the Protocol Relating to the Status
of Refugees. These governments should also stop violating the human rights of
migrants. Refugee status for migrants fleeing their home country due to fear of
persecution prohibits routine deportation and increases the availability of services and
assistance, including medical care, to limit the spread of infectious diseases among highly
mobile populations. Moreover, state-sponsored discriminatory policies and practices, as
well as state-condoned vigilantism by private groups, only serve to drive migrants further
underground and prevent them from seeking medical care when they are ill or injured.
Recent trans-border cooperation between India and Burma to capture ethnic insurgents
has resulted in increased abuses against migrants including arrest, mistreatment, torture,
and execution.
• The Government of Burma should take steps to halt the internal armed conflict and
violations of international human rights and humanitarian law that are creating an
unprecedented number of internally displaced persons and migrants. Internal armed
conflict and abuses of rights, including forced displacement and forced labor, are creating
major social upheavals leading to thousands of people fleeing their homes and living in
internally displaced persons camps within Burma or in migrant camps on the border
regions. These camps lack adequate food, sanitation, clean water, shelter, and medical
care. Large mobile populations living under such poor conditions may be a conduit for
the introduction of infectious diseases such as TB, malaria, HIV/AIDS, lymphatic
filariasis, and avian influenza to new and unprepared communities.
• The Government of Burma should recognize citizenship for the Rohingya in Arakan
State by repealing or amending the 1982 Citizenship Law. Until that time, the United
Nations High Commissioner for Refugees (UNHCR) must provide adequate resources
to the Rohingya who are languishing in refugee camps in Bangladesh. Under the 1982
Citizenship Law, the members of the Muslim minority in North Rakhine State, generally
known as the Rohingyas, have been denied Burmese citizenship, which has seriously
curtailed the full exercise of their human rights and led to various discriminatory
practices, including restricted access to medical care, food, and adequate housing. These
oppressive practices have caused waves of Rohingya migration out of Burma into
Bangladesh where they currently live in refugee camps administered by UNHCR. These
camps are sorely inadequate, leaving the Rohingya in fetid, overcrowded living
conditions where health care is lacking and the TB infection rate is soaring.
Responses to Infectious Diseases in Burma’s Border Regions
• UN agencies, national and local governments, and international and local NGOs must
cooperate closely to develop health care programs along Burma’s borders. Some of the
highest rates of TB, malaria, and HIV/AIDS in Burma are found along its frontiers. Yet
the Burmese government provides little or no public services, including health care, to
people living in the border regions and limits the travel of international organizations to
conflicted areas of the border. Some ethnic-based organizations provide health care in
these areas, but their resources are extremely limited. These organizations need to receive
greater support. In addition, health care programs must be initiated across the border and
brought to the Burmese frontier. The Back Pack Health Worker Team operates out of
western Thailand and sends supplied health care workers on foot into eastern Burma to
gather medical data and provide medical treatment and preventative care. It represents
one successful cross-border model that should be expanded and replicated on Burma’s
borders with China, India, and Bangladesh.
• The governments of Burma and its neighbors must stop obstructing the passage of
medical supplies and health care workers across the borders and develop national
policies that promote cross-border health care. The Burmese frontier appears to be
permeable to almost everything—people, timber, gems, natural gas, and infectious
diseases—except public health programming. In order for cross-border health programs
to reach people living in Burmese conflict and cease-fire zones, the governments of
Burma and its neighbors must stop obstructing the passage of medical supplies and health
workers and develop national policies to support these efforts.
Regional Coordination and Response
• UN agencies, national and local governments, and international and local NGOs must
cooperate closely to facilitate greater information-sharing and collaboration among
agencies and organizations working to lessen the burden of infectious diseases in
Burma and its border regions. These institutions should also work together to develop
a regional response to the growing problem of counterfeit antimalarial drugs. In
January 2007, our two centers, in collaboration with the Global Health Access Program,
convened a regional conference on “Responding to Infectious Diseases in the Border
Regions of South and Southeast Asia” in Bangkok, Thailand. The conference brought
together 190 participants, representing 95 institutions from nine countries—Australia,
Bangladesh, Burma, China, India, Thailand, Singapore, United States, and Vietnam—to
discuss the efforts of governments, UN agencies, nongovernmental organizations, and
health clinics to combat infectious diseases in Burma and its border regions. Conference
speakers highlighted some of the key challenges health professionals face as they
confront the spread of communicable diseases in the region. These include limited
disease surveillance and data collection; divergence of “official” statistics with data from
conflict zones; the paucity of data from narcotics surveillance, including drug availability
and use and data on infectious disease prevalence and incidence among drug users; lack
of prevention and treatment programs; and widespread violations of international
humanitarian law and medical neutrality in some border regions that restrict the ability of
health professionals to access vulnerable communities.
Conference participants, especially from the NGO sector, stressed the need to: (1)
implement a mapping process, utilizing global-positioning technologies, to record the
location, activities, and service-range of health-based organizations working to combat
infectious diseases in Burma and the border regions; (2) convene a series of borderspecific
training workshops to standardize procedures for surveillance, data collection,
analysis, and dissemination of information about infectious diseases in the region; (3)
convene a second regional conference to report on the progress in implementing
standardized procedures for data collection and analysis and to meet with colleagues and
donors from the region; and (4) promote the development and capacity of communitybased
health organizations to provide health care for their own people.