Health and Human Rights in Post-Conflict Eastern Burma: Militarization, Risk and Community Responses.

다국어 초록 (Multilingual Abstract)

Background.
Despite recent political reforms in Burma, human rights abuses are ongoing in ethnic regions in the country. Fighting continues in some areas, and ceasefires in others have not brought an end to human rights violations. In response to political reforms, the international community has decreased political and financial support for ethnic communities in Burma, leaving them more vulnerable than ever. Continued advocacy for an end to human rights abuses and for continued humanitarian support for ethnic groups in Burma is greatly needed. The goals of this project were to gather evidence of human rights abuses in Karen state, eastern Burma, identify health consequences of these abuses and use the data to advocate for justice for victims.
Methods.
We created a framework to describe social determinants of health in Karen state and used it to generate hypotheses about the effects of militarization and human rights violations on health and the role of village responses in moderating these effects. A second framework was used to operationalize international human rights law into a survey instrument applicable in Karen state.
We then conducted a systematic literature review to determine state-of-the-art methods for cluster sampling in conflict areas and to identify cases in the peer-reviewed literature when security precautions may preclude following best practices for sampling. Using the best practices identified by the literature review, we conducted a two-stage cluster survey of 686 households in eastern Burma in January 2012 that covered health status, access to healthcare, food security, exposure to human rights violations and identification of perpetrators. Data analysis included descriptive and interpretive components. We used logistic regression to identify associations between exposure to armed groups, village responses, human rights abuses and health outcomes.
Results.
This project provided timely data that documented human rights abuses in Karen state and the need for humanitarian assistance. Data was used to advocate for continued humanitarian aid for ethnic areas, continued pressure on the Burmese government to stop human rights abuses and for perpetrators of human rights abuses to be held accountable for their crimes.
Household hunger, measured by FANTA-2 scale, was low in 581 (84.7%) households, moderate in 85 (12.3%) households and high in six (0.9%) households. Households reporting food shortages during any month in 2011 ranged from 19.9% to 47.0%, with food insecurity peaking just prior to the harvest. Diarrhea prevalence in children was 14.2% and night blindness in women of child-bearing age was 5.6%.
Forced labor was the most common human rights violation, reported by 185 households (24.9%); 210 households (30.6%) reported experiencing at least one human rights violation in 2011. Multiple logistic regression analysis identified associations between human rights violations and poor health outcomes.
Novel Findings.
This is the first study to assess the latest methods for cluster sampling in conflict areas. We found that researchers doing cluster surveys in conflict areas must sometimes alter methods to ensure safety and security of field surveyors. Common alterations are skipping and replacing clusters that are insecure, making fewer attempts to revisit empty households, using fewer field supervisors and making contextual decisions on how best to allocate households to clusters. Several common security protocols are identified.
This is also the first study to examine militarization and village responses in Burma. Close proximity to a military base was a predictor of human rights violations, inadequate food production, inability to access healthcare and diarrhea. Exposure to armed groups predicted these outcomes and also household hunger. In households that reported no human rights violations, risk of household hunger, inadequate food production, diarrhea and child diarrhea increased when neighbors' households reported human rights violations. Households in villages that reported using any self-protection technique had lower risk of experiencing human rights violations. Households in villages that reported negotiating with the Burmese army had lower risk of human rights violations, household hunger, inadequate food production and diarrhea. Stratified analysis suggests that self-protection may modify the effect of exposure to armed groups on risk of human rights violations and some health outcomes.