YANGON, Myanmar — In a tiny wooden home in an impoverished corner of Yangon, a gauzy white hammock swung from the rafters.
Inside that hammock lay baby Khin Phyu Zin, who grew longer and heavier, while her grandmother, Daw Aung Kyi, 54, pushed the swing and dreamt about the baby’s future.
Daw Aung Kyi was the child’s primary caretaker, watching the toddler grow while her mother sold snacks from a mobile food cart. She wanted Khin Phyu Zin to be a doctor. It was an ambitious but not impossible goal for a young girl born into a poor family in a deeply traditional society emerging from five decades of military dictatorship and heading into the hope and uncertainty of a new democracy.
But in early June 2013, when she was 2, Khin Phyu Zin developed diarrhea. The fluid pouring out of her was milky white, a symptom of cholera. Earnings from the food cart barely allowed the family to eat, so Daw Aung Kyi borrowed money for a taxi ride to a hospital 10 minutes away. She later sold the family’s most valuable assets — two gold rings — to pay for expenses related to care.
When Khin Phyu Zin started getting better, her family brought her home. But the diarrhea returned, and in late June 2013, several hours before daybreak, the toddler died in her mother’s arms, one hand splayed across the chest of her sleeping older sister.
“We tried as much as we could to save that baby,” said Daw Aung Kyi, her long, round cheeks and plum-colored lips covered in tears. “Nothing is more precious than a human life.”
After the child died, a neighbor called the Free Funeral Service Society, a nonprofit group that arranges cremations for grieving families. One of the organization’s two baby hearses — white cars specially fitted with diminutive glass coffins — came to collect the child’s body, and the car’s red-and-blue police-style lights flashed as the vehicle trailed away.
The high rate of child death in Myanmar is among the most painful legacies left by the military dictatorship that ran the country from 1962 to 2011. During that time a corrupt and brutal junta shifted the country’s abundant resources to military spending and military industry rather than investing in a progressive health care system. In the years following World War II, Myanmar had the best health care system in Southeast Asia. Today, one in 15 children in Myanmar will not live to see his or her fifth birthday, according to UN data — the highest under-5 death rate the region. Between 56,000 and 70,000 children die here every year, largely of preventable causes.
Save the Children, which ranks the world’s countries in terms of best and worst places to be a mother, puts Myanmar at 152 of 176 countries, worse than Afghanistan, Sudan and India.
Representatives from international health organizations here use phrases like “total neglect” and “complete absence” to describe the military government’s role in promoting the well-being of the country’s citizens. As late as 2005, annual government spending on health care was just 376 kyat per person, about 38 cents in US dollars. Total health care spending — including government assistance, foreign aid, and individual payments — is still just $8 per person.
Many wealthy countries stopped donating to Myanmar during the five decades of military rule, saying that their efforts were being strangled by government restrictions on aid work, and that they were unwilling to funnel money to a government they believed would use it to repress its own people.
On a micro level, the deaths have had devastating effects on families. Days after the loss of baby Khin Phyu Zin, her mother moved to another town, leaving Daw Aung Kyi, already a widow, feeling abandoned by both her granddaughter and her daughter-in-law.
On a macro level, the devastating loss of young lives could cripple Myanmar’s economy just as it is emerging.
“All countries that suffer a high rate of child mortality have underdeveloped economies because of it,” explained Christopher Duggan, a professor at the Harvard School of Public Health who studies nutrition in resource-poor settings.
The government seems to realize this. In fiscal year 2012-2013, Myanmar dedicated about three percent of total expenditures to health care, up from one percent the year before. Large aid groups that were driven away by the previous government are returning.
And new ones are coming in.
Managed well, this injection of aid and turn in policy could dramatically reduce the number of child deaths in Myanmar. But the country’s dark and unique history means that many challenges lie ahead.
THE ROOTS OF MYANMAR’S CHILD HEALTH PROBLEM
The 1962 military coup that seized control from Myanmar’s democratically elected government ushered in nearly 50 years of extreme poverty and repression. Many foreign governments cut economic ties with the ruling generals, severing the country from most of the world. China became Myanmar’s primary trading partner, but the relationship did little to help the country’s citizens. China extracted Myanmar’s riches — timber, minerals, gas — while the generals imported arms used to wage war on dissenting factions.
By 2007, Myanmar was receiving just $4 per person in overseas development assistance, less than any of the world’s poorest 50 countries. Cambodia and Laos, nations with similar poverty levels, received $47 and $68, respectively, according to the Organization for Economic Cooperation and Development.
This isolation affected health funding. The Global Fund, the world’s largest financier of anti-AIDS, tuberculosis, and malaria programs, pulled its donations from the country in 2005. The move was controversial, and many health-oriented groups in Myanmar strongly opposed it, saying it would hurt the people who needed the funds most.
At the time, the Global Fund had promised nearly $100 million in aid over five years.
“The Global Fund’s decision to pull out of Myanmar was unprecedented,” wrote Jane Parry in a World Health Organization bulletin just after the decision. The fund’s donors had previously placed restrictions on the use of funds in Cuba, Iran, Sudan, and Ukraine “to ensure that funding is used for its intended purpose and not to benefit the government.” But the Global Fund had completely pulled out of only one other place: North Korea.
While Myanmar’s neighbors charged into the global Internet age, the country’s leaders watched from their crumbling towers of isolation. Its people, meanwhile, became poorer, sicker and more detached from the outside world. In the 2000s, inflation surged upward, while wages remained stagnant.
“In the Delta region, where rice production has declined, landless peasants are resorting to scavenging to find a meal,” wrote Johns Hopkins professor Bridget Welsh in a 2003 op-ed in the New York Times. “In the Rakhine district, anemia is increasing. In the arid central zone near Bagan, chronic malnutrition levels match those of Somalia and Sudan.”
By the 2000s, the generals faced a dilemma. They could stay the course and face a near certain tumble into more disastrous poverty, or introduce reforms that would move the country toward a market economy. To accomplish the latter, they would have to prove to the world that they were ready to change. Thus began a campaign to woo the West.
In 2010 an election was held, the first in 20 years. The vote was designed to transition the government from one that was completely controlled by the military to one that was partially controlled by civilians and partially controlled by the military. Afterward, everyone but the victors agreed that the election was a stage-managed sham. Turnout was low, and the leading opposition party did not even participate.
“The semblance of reform, however, has improved Burma’s standing in the international community,” wrote Bertil Lintner, a journalist and leading Myanmar expert.
Since the new government came to power in 2011, it has, in fact, introduced many reforms. Pre-censorship of media is gone. Unions are legal. Many political prisoners are free. A second election was held to fill vacant parliament seats, and the country’s most famous dissident, Aung San Suu Kyi, joined the government.
Health care, President Thein Sein has said, will be part of this remodeled nation. Instead of snubbing the international intelligentsia — a habit that was common during the reign of the generals — the new president is welcoming outsiders in.
He has also promised to put in place a system that provides universal health care.
“We will improve quality of … hospitals … the skills of medical staff… the quality of rural health centers,” he said in his inaugural speech. “In the process, we will work together with international organizations, including the UN, INGOs, and NGOs.”
STAGNANT WATER, STAGNANT HEALTH CARE
Nyo Ma, 33, a construction worker with a heart-shaped face and golden skin, lives in one of the poorest corners of Yangon’s Hlaing Thar Yar Township. Her tiny home is much like that of the tens of thousands of low-wage workers in Yangon, except that it shimmers with a bit of personality. The outside walls are green, not brown. Inside, a Buddhist altar is cloaked in purple tinsel.
Nyo Ma said child deaths are part of the rhythm of daily life here. Clutching one of her three living daughters, age nine months, she described the conditions that led to the loss of a baby son seven years ago.
She moved to Yangon more than a decade ago, fleeing rural poverty in a village in Mon State. But it has been difficult, she said, to create a safe, stable life for her family. Construction jobs come irregularly — when there is work, she earns about $3 a day, her husband about $4 — and the family cannot afford to live anywhere else.
“Children get sick here because of the environment,” she said. “I don’t want to be rich. I just want a life where the family lives happily.”
Her community is a long ribbon of bamboo homes, each stacked on stilts above a shallow, sludgy green-brown swamp. The stagnant water below is a playground for bacteria, scattered with trash and the occasional dead animal. Nyo Ma and her neighbors filter well water through a cloth sleeve, a method that does not kill bacteria or viruses. Toilets are outhouses with pipes that lead into the swamp below.
During her pregnancy, Nyo Ma needed money, so she lugged stones and mixed concrete until she gave birth. When her son was born, she said, she could not produce milk. So she gave him formula instead, mixing it with the cloth-filtered water.
One day, when he was two months old, her son began crying and would not stop. He wailed for three days, then suddenly died.
“It was too soon,” she said. “I still want a little boy.”
Diarrhea — a symptom of infections caused by bacterial, viral, and parasitic organisms carried in feces-contaminated water — is one of the leading causes of child deaths in Myanmar, as in much of the developing world, despite the fact that simple prevention and treatment methods have existed since at least 1968.
Public health experts have long advocated a recipe for preventing diarrhea: clean drinking water, hand washing with soap, regular washing of food and bodies, and receiving education about how infections spread.
They also say that for the first six months of life, a child should be breastfed and not given water or solid food.
But in this part of Hlaing Thar Yar, such a regimen is difficult to follow. Mothers said they add solids to children’s diets because they must return to work. Child care is left to siblings or grandparents. Across the country, just 24 percent of mothers breastfeed exclusively for the first six months of a child’s life, according to a survey conducted in 2009 and 2010by the government and UNICEF.
And prevention is not the only issue.
In theory, diarrhea treatment is not prohibitively expensive nor difficult to find. Oral Rehydration Solution (ORS) is a low-cost, life-saving, time-tested solution of salt, sugar, and water. It can be administered at home or in a clinical setting, and is available in prepackaged packets. Even using contaminated water to make the solution is better than not giving the treatment at all.
ORS is available in all health facilities in the country, according to Dr. Kyu Kyu Khin, a technical officer in the mother, child, and newborn health unit at the World Health Organization in Myanmar. And all health workers are trained to administer it, she said.
But the 2009-2010 government survey indicates that just 50 percent of child diarrhea cases are treated with the WHO’s recommended response: ORS, increased fluids, and continued feeding.
Parents, said Dr. Kyu Kyu Khin, are not convinced that this is the proper treatment, and no one has been able to sway them otherwise.
“There is a belief that to give feeding during an episode of diarrhea will worsen the diarrhea,” she said.
Many also avoid hospitals and clinics until it is too late, fearful of the inevitable costs associated with care.
Nyo Ma lives about three miles from Hlaing Thar Yar General Hospital, eight miles from Yankin Children’s Hospital and nine miles from Yangon Children’s Hospital. When her son became sick, however, she did not seek professional assistance, she said, scared off by a possible hospital bill and unable to afford a taxi fare — somewhere between $3 and $6.
Most people in her neighborhood make about $3 a day, and common childhood illnesses often lead to catastrophic bills — $100, $120, $250 — that take years to pay off. Parents sell or pawn jewelry, furniture, even entire homes to pay for children’s hospital stays.
“The whole block is in debt,” said one neighbor, Daw Htay Yee, 47.
In Yangon, this reluctance to seek medical help has manifested itself in tragic way. A newly built children’s hospital has too many beds and not enough patients.
“People in this area didn’t dare come here,” said Dr. Aung Myint Lwin, medical superintendent at Yankin Children’s Hospital. He said that the sturdy, freshly painted building led people to assume it was a private facility and thus beyond their reach financially.
In March 2011, the hospital opened with 500 beds. In 2012, he said, he filled just 100 of those beds on an average day.
In the absence of an affordable, accessible system, traditional healers have flourished, and many parents in Hlaing Thar Yar said they turn to traditional medicine before heading to a medical facility.
In the case of diarrhea, this can be fatal. Healers sometimes help. But they are also known to perpetuate harmful practices, counseling mothers away from ORS or breastfeeding.
“This is the weakness of the medical system,” said Ko Nyi Nyi, a former political prisoner who runs schools and a health clinic in poorer neighborhoods. “If someone gets sick and they have money, they survive. If they don’t have money, they don’t survive.”
Encouraged by the country’s reforms, the Global Fund returned in 2011. Other organizations, both private and public, are reentering the country or considering working there for the first time.
Several countries have dedicated $300 million toward a pool of money called the Three Millennium Development Goal (3MDG) Fund, which aims to strengthen the government health system over a five-year period. Two-thirds of that money will go to improving maternal, infant and child health. The fund’s donors are Australia, Denmark, the European Union, the Netherlands, Norway, Sweden and the United Kingdom.
Much of the 3MDG money will be used to help train and retrain unpaid community health volunteers, the foot soldiers of Myanmar’s health system.
Whether an influx of funds will improve the landscape remains to seen. Even radical reform to the health care system will not change many of the underlying causes of disease: poor sanitation, for example, or low wages and erratic work schedules that lead to poverty.
“You need a series of interventions,” said Geoffrey Poynter, deputy country director for program development and quality at Save the Children in Myanmar.
What is clear is that there is an overwhelming call for change.
In Yangon, the Free Funeral Service Society, which collected the body of baby Khin Phyu Zin, picks up 35 to 45 dead children each month. Since its founding in 2000, the organization has grown to a fleet of 20 hearses, two of which are used only for children. The second child car was added in 2013, because of the rising demand.
On a recent July day, a thin first-time father named Sai Kahn Zaw stepped out of one of the baby hearses at Yay Way Cemetery. He then trailed a pair of men pushing a glass coffin that held his lifeless unnamed son.
At the door to the crematorium — where the baby’s ashes would be swept away unceremoniously, in the local tradition —Sai Kahn Zaw tilted his chin upward, pushing tears back into their sockets, before leading his son’s body inside.
“I would like this not to happen again,” Sai Kahn Zaw said. “Children should live longer. There are too many needs, too many cases like this.”