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Borderline Health

Borderline Health

Borderline Health (continued)

By Cathy Shufro

The connection between human rights and health drew Mullany to the work he does now. After graduating from college in 1997, he was volunteering for a public health project in Angola when he first recognized that health might hinge on politics. "It hadn't occurred to me that children would miss out on polio vaccinations because there was fighting or land mines, or no 'cold chain' [system for delivering refrigerated vaccines]."

In Burma, stories of brutality had been collected for years by Human Rights Watch and the Karen Human Rights Group. But, as Mullany points out, when people in power are confronted with an account of wrongdoing, "What's the typical response? 'That's an isolated incident. That unit has been disciplined.' ... But if you have quantitative data, you can argue: 'No, that's not an isolated occurrence. We did a population-based representative survey that showed the percentage of the population that's been forced to move, whose food supply has been stolen, who has been forced to relocate, faced forced labor, faced direct attacks.' "

Collecting data also locates pressing needs. A survey by the Back Pack medics showed that pregnant women in eastern Burma got very little health care. This worried the ethnic health departments that manage health care in regions of Burma abandoned by the central government. They had trained traditional midwives to attend births. But when they saw the high perinatal death rates, says Mullany, they realized that "in order to save women's lives, you need people who are trained to provide emergency obstetric care."

In a war zone, it's impossible for all mothers to give birth in clinics. So the MOM Project brings birthing experts to the mothers.

The ethnic health departments decided to provide that training. In 2005, they established a pilot program, the Mobile Obstetric Maternal Health Workers Project—nicknamed the MOM Project. They began with a target population of 60,000 in four eastern frontier states (Shan, Karen, Karenni and Mon states). Mullany and Beyrer advised the project, which received a large portion of its $200,000 annual budget from the Bloomberg School's Bill and Melinda Gates Institute for Population and Reproductive Health.

The aim of the project—safe delivery—is not unusual, but its novel approach reflects the geographical and political realities of eastern Burma. The conventional way to improve perinatal survival is to get women into well-equipped clinics with trained staff. But in a war zone, as Mullany puts it, "a focus on facility-based delivery is not a feasible short-term option." Even the rudimentary clinics that MOM has built have been vulnerable to army attack, and more permanent structures would attract unwanted attention. Furthermore, centralized clinics may be several days' walk from remote villages, and changing routes to avoid soldiers can delay travel by days or weeks.

So the MOM Project trained mobile health workers, equipping them to handle emergencies in women's homes. "That's what makes the MOM Project unique," says Mullany. "It's about bringing the services to the people rather than bringing the people to the services."

Soon after her cousin's death in 2005, Naw Tha Mu heard about the MOM Project. She'd already completed basic medical training, and the Karen Department of Health and Welfare chose her to be among the project's senior maternal health workers. In August 2005, Naw Tha Mu crossed into Thailand to join 32 other men and women for eight months of study in the border town of Mae Sot. They got hands-on experience attending births at the Mae Tao Clinic, founded by the revered Burmese doctor-in-exile Cynthia Maung, MD, who started the free clinic to care for refugees after the Burmese government killed thousands of student demonstrators in 1988. Maung helped design the MOM Project, and her clinic provided the volume of practice that the trainees needed: about 2,000 babies are born there each year. The project's field coordinators, first Catherine Lee, MPH, and now Kate Teela, MHS '08, have run the program along with five full-time staff from Burma.

The students learned routine care, including screening women for anemia and malaria (which can increase postpartum bleeding), resuscitating newborns in distress, and advising mothers about contraceptives ranging from condoms to Depo-Provera. They learned to use medication to reduce blood pressure and fight infection, and to remove a retained placenta after birth or miscarriage. They learned to use drugs to prevent postpartum hemorrhage, the leading cause of maternal death worldwide, and to give blood transfusions to treat it.

The 33 senior maternal health workers went home to run two months of training for 131 midlevel health workers and briefer sessions for 288 traditional birth attendants. Every village would have a traditional birth attendant, along with a midlevel health worker in the village or nearby. Senior health workers like Naw Tha Mu went to live in centrally located villages, ready to travel.

One key aspect of emergency care—blood transfusion after hemorrhage—had posed a problem. Without refrigeration in the clinics, how could blood be stored?

So the MOM Project innovated a plan for "walking blood banks" composed of villagers. The senior maternal health workers would type the blood of anyone volunteering to donate and save that information. In an emergency, runners would search the village and the rice fields to find several donors with the required blood type. The health workers would screen them on the spot with rapid diagnostic tests for diseases like malaria, hepatitis and HIV. Those who tested negative could give blood immediately.

The walking blood bank has proven successful, and the Bloomberg School's Beyrer thinks it could save lives in any place without refrigerators. "The blood is stored in the healthiest place there is: the human body," he says.

Donated blood saved a 34-year-old pregnant woman in Karenni State last year, says senior maternal health worker Aka Kyeh Pwin. After being bitten by a venomous green snake, the woman was bleeding heavily from the vagina, her cervix dilated. Aka Kyeh Pwin sent runners to search for the 10 potential blood donors in the village. Four people arrived, and all tested free of disease. Together, they donated five units of blood. The baby born the next day died after taking two breaths. But the mother of four children was well within a month. "She would have died without that blood," says Aka Kyeh Pwin.

IT'S LATE AUGUST, and Teela, the MOM Project coordinator, is counting villages. Sitting in an open-sided cinderblock building with a leaf roof on the outskirts of Mae Sot, she compares two lists of villages. She needs to calculate how many settlements in the MOM target area have disappeared and how many new ones have been established. As usual, a few villages have disappeared, and others are new. No clinics have been lost, though; in 2006, one of the 12 was burned by Burmese soldiers. Teela needs to know the number of villages so she can make 11th-hour adjustments to the plan for a population-based survey of the families served by the MOM Project.

To have blood ready for post-hemorrhage transfusions, MOM Project workers rely on "walking blood banks."

Teela is elated that 14 of the 16 members of the survey team have made it to Thailand to prepare for the final MOM Project survey. Twenty-one maternal health workers have come, too. Some have traveled for days to get here, on foot, by motorbike, in boats and in cars. They meet, eat and sleep in open buildings beside a field where cattle graze.

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