The International Rescue Committee's Burma Border Program: Mae Hong Son Office Program History - The First Five Years

Transcription

1 The International Rescue Committee's Burma Border Program: Mae Hong Son Office Program History - The First Five Years Prepared by : Kerry Demusz - Program Coordinator (April October 1996) February 1997 ^ %

2 Table of Contents Foreword:... 4 Program History:... 5 Background:... 5 Refugee Medical Structure:... 6 Medics... 6 Medic Assistants... 6 MCH workers... 6 Laboratory technicians... 7 Community Health Educators... 7 Sanitarians... 7 Brief Notes about each Program:... 7 Clinical Care: Maternal and Child Health (MCH):... 8 Community Health Education:... 8 Sanitation:... 8 Vocational Training and Capacity Building... 9 IRC Assistance in the Northern Karen Camps:... 9 IRC Personnel Personnel: (by year end) Relations with the Royal Thai Government (Local Level): Program Support : Donors The Refugee Profile: Background: Karenni Ministerial Structure and Relief: Camp Administration: Health: Education: Table 1: Percentage Distribution of Highest Level of Completed Education by Age and Sex Religion: The Karenni Camps - Population, Moves and Locations: Population:... T Table 2: Karenni Refugee Population by Year End Camp Locations and Moves: Camp #1 - Bang Yon Camp #

3 Camp #3: Nai Soi Camp #4: Huay Nam Rin Camp #5 Mae Surin: Camp #6 - Baw Nya Hta: Site # 1 and Site #2: Non-Governmental Organizations and the Karenni: General Conclusions: Positive Aspects of the Program Problems / Interventions with the Programs: Conclusion: References: Maps... 29

4 Foreword: This paper is an attempt to recount the highlights of the first five years of the International Rescue Committee's Burma Border Program based in Mae Hong Son. As such, it does not relate other important aspects ofirc's involvement with refugees from Burma, including programs aimed at assisting the All Burma Student's Democratic Front (ABSDF) members, beneficiaries of Dr. Cynthia's clinics, or urban refugees assisted through the Bangkok office. It does however, provide context and background to the Mae Hong Son program which has changed significantly over the five years from a small sanitation and health education program for 5,000 refugees - to a comprehensive primary health care program serving almost 11,000 refugees. The paper is divided into three main sections. Firstly, there is a history of the program - including details about specific programs and personnel, secondly, the refugee profile - including information about the Karenni camps, their structure location and administration and lastly, some closing notes about positive aspects and problems of the program. Iwould like to thank a number of staff who helped with compilation and editing of this document. Tanks goes to Helen Dalton - Country Director, Justin Sherman - Burma Border Program Field Coordinator, and Jeanne Hodaian - Capacity Building Program Manager. It is hoped that this document will serve as a record of the development of the program and provide insight for new staff, current donors and other parties interested in the work of IRC with the Karenni.

5 Program History: Background: In late 1991, the Inter ational Rescue Committee (IRC) conducted a preliminary assessment of the Karenni camps with an aim towards initiating a primary health care program for Karenni ethnic minority refugees from Burma. At the beginning of 1992, the IRC established a small office in Mae Hong Son in order to work with the Karenni. The program was started at the invitation of the Coordinating Committee for Services to Displaced Persons in Thailand (CCSDPT)' and Medicins Sans Frontieres (MSF). Initially, the program was very small, consisting of three IRC staff people (2 expatriates and one Thai), a coordinator, a sanitarian and a health educator. An expatriate nurse position was soon added to the team in order to improve supervision of health care services. During this time, due to constraints imposed by the Royal Thai Government's Ministry of the Interior (MOI), who is responsible for monitoring and mandating international NGOs providing services to refugees, IRC was not directly distributing medicines or monitoring health care. This was because MSF- France was the only agency on the border mandated to provide this service. The program initially focused on establishing basic sanitation systems, providing health education to the community and developing relationships within the community.2 In mid-1992, IRC did initiate an Emergency Medical Referral (EMR) Program, which provided refugees with access to Thai government health structures for treatment of emergency and/or life threatening medical conditions. The EMR program was the first medically related intervention undertaken. Beginning in 1993, the program began to find firm footing with the Karenni and slowly began to expand as the needs of the population began to present themselves. In 1994 the program changed significantly, because IRC became formally mandated by MOI to provide health services in Karenni refugee camps. At this time, IRC took over the purchasing of medicines from MSF and began directly monitoring the health situation in the camps independently: During 1994, more intensive training for assistant medical staff and a new cadre of preventive health workers - Maternal and Child Health (MCH) workers was also started. During 1994, training for MCH workers on Ante-Natal Care (ANC), Post-Natal Care (PNC), Sterile Delivery, Child Health and Nutrition and Family Planning created a basic MCH program that had previously been lacking in the camps. CCSDPT in the absence ofunhcr, is the body which coordinates relief services for Jill of the ethnic minority refugees on the Thai-Burmese border. At the outset of the IRC program, sanitation and health education work was also conducted with the residents of Mon refugee camps. However, because the Mon camps were two days travel from the Karenni camps, IRC did not work with the Mon for very long, but rather handed the program back to MSF. e

6 In late 1994, IRC also expanded programs to include a laboratory diagnostic program, increased immunization coverage and expanded family planning services for Karenni refugees. IRC also formalized the Community Health Education program, which focused on training refugees as health educators in their communities. In 1997 all of these programs are on-going and an additional Capacity Building program will be initiated. Refugee Medical Structure: Preventive and curative care is provided in each camp by trained refugee implementors using a community based primary health care approach. Each camp has its own clinic, laboratory and MCH center (often the same building, but sometimes situated in a common compound). IRC provides training, technical assistance and supplies to these programs and monitors their progress. The refugees themselves supervise and run the health programs through their gover n ment's Minister of Health and Education (formerly the Director of Health). This Minister officially oversees all of the programs, deals with personnel issues concerning the refugee medical staff and is involved in the planning and implementation of activities. On a day to day basis, these tasks have been handled by the Minister's Deputy for Health and the Karenni Medic Supervisor. These people are IRC's day to day contact regarding program implementation, scheduling and training. Currently, there are six designated types of health workers; Medics are in charge of the clinic and the overall health status of the residents in the camps. They provide curative care, education for patients and supervise all of the other medical staff. Medics generally haver years of training that has been provided by either MSF-France, AMI-France or was received by the medic while still inside Burma. Continuing medical education classes are provided -^er medics to standardize and upgrade knowledge on a monthly basis. Medic Assistants are general assistants in the clinics, who do intake work, distribute medicines ordered by the medic, monitor patients in the in-patient dispensary and sometimes do basic curative care. Medic assistants generally have 2 months of training and do most of their learning "on the job." They also receive continuing medical education and are often re-trained as medics, MCH workers or lab technicians after some time as n-redic assistants. A new group oftb medic assistants will be trained in 1997 to oversee the tuberculosis control program, MCH workers have a primarily preventive role. Their work consists of screening women for ANC, conducting deliveries using sterile techniques, conducting PNC visits, child growth monitoring, immunization, counselling and services for family planning,

7 health education and school health activities. They work in conjunction with the clinic and laboratories. Laboratory technicians are.a specialized group of health workers, whose role is to provide increased diagnostic capabilities to the medical workers. In the area of the program's work, resistant falciparum malaria is endemic, as are cholera, shigella dysentery and various other parasitic diseases. The laboratory technicians have been trained to conduct basic laboratory examinations for malaria, tuberculosis, paragonimiasis, other parasites, as well as conduct basic stool and urine tests. These tests aid the medics and MCH workers in diagnosis and preventive care for refugee patients. There are also a small cadre of Community Health Educators (CHEs) whose role is to provide adult oriented health education to the refugee community about preventing disease. The CHEs use a variety of visual aids and languages to accomplish this task. The final group of health workers are the community Sanitarians. The sanitarians are responsible for environmental hygiene in the camps, including safe water, latrines, rubbish disposal and vector control. Working together, all of these people form the basis of the Karenni health care system. In 1994, prior to the initiation of IRC training there were only approximately 20 medical workers in the camps. Today, there are more than one hundred. IRC has maintained a training and monitoring oriented approach to assistance in the camps. IRC provides both formal training courses and case based training during monitoring visits. In addition, IRC provides most of the supplies that maintain the health care system. IRC's philosophy regarding work with the Karenni has focused on providing training that the refugees can use and take back with them to Burma. All programs are initiated in a community based manner and refugees are either asked to contribute labor or materials to the projects that they have agreed to implement: In recent years, IRC has tried to train and work with more Karenni trainers, who can implement future training for new medical staff on their own. This approach is based on the idea that if more people can run the system independently, it is more likely that the system (or at least part of it) will survive the transition from a refugee setting to a return to their home country in the event of a repatriation. Brief Notes about each Program: Clinical Care: IRC first began partial monitoring of clinical care during 1992, when a public health nurse position was added to the team. As was mentioned above, another crucial part of the program, which is referral to secondary and tertiary health care services was introduced in mid For more information about the Emergency Medical Referral program and its impact, please see the December 1994 Evaluation Report.

8 . In mid-1994, when purchasing and supplying of medicines was taken over from MSF, IRC started to play a much larger role. It was also at this time that IRC started to provide refresher training for medical workers in the camps (medics and medic assistants). Reliable data on morbidity and mortality trends have only been collected by the IRC program since this time. In late 1994, another important part of the clinical care (and preventive care) program was initiated in the form of laboratory technician training. Because falciparum malaria is endemic in the area where the refugees reside, accurate, quick access to laboratory diagnosis of malaria is essential. The training program has been very successful and refugee laboratory supervisors were able to take over the training component for new lab technicians within one year of the program's inception. In mid-1996 as a result of the large influx of new arrivals into the camps and the lack of a strong Tuberculosis Control Program, a temporary position was added to the team in set up an effective system. Also as a result of this influx and additional medical doctor has joined the team to conduct new training for refugee medics. Maternal and Child Health (MCH): The MCH program, including training, provision of supplies and monitoring of the Maternal and Child Health aspects of refugee health started when the first training was held in early The first training focused on providing MCH volunteers with skills in sterile delivery, ante-natal care and post-natal care. This training was soon followed by an intensive workshop on Child Health and Nutrition. The final topic introduced to the MCH workers was family planning. In 1993, immunization campaigns focusing on covering children under 5 for measles started in the refugee camps. In 1994, the campaigns expanded to provide coverage for all WHO recommended immunizations in all camps in the Karenni and Northern Karen area. In most camps now, immunization is conducted on an on-going basis. Only in Camp #2 are campaigns (to cover new arrival children and reproductive age women) still necessary. MCH services are now offered in all camps (except Camp #4) as part of the preventive services offered by the clinic. Regular upgrading training and bi-monthly MCH worker meetings are sponsored by IRC. In 1996 and 1997 special emphasis on training a senior MCH worker to take more responsibility for monitoring the program and conducting training has been a major focus. More information about the reproductive health side of the MCII program can be located in the Refugee Reproductive Health: Status of Current Programs Report compiled in September Community Health Education: Although the IRC program started with an interest and a commitment to health education, because there was such a large need for trained refugee medical personnel in the camps at the outset of the medical program, health education was slowed considerably during Then, as aresult of increased funding, the program was able to start again in earnest. In early 1995, a full time program manager was hired to establish the program and a program assistant was added in

9 mid This program has focused on developing appropriate health education materials for use along the entire border and training refugee community health educators. A survey and evaluation of the impact of the program is being conducted in early Sanitation: One of the biggest strengths of the IRC program has been its sanitation program. While initially, there were some problems with the level of technology used, the systems which are now in place typify appropriate, replaceable technology. The systems are constructed and maintained entirely by the trained community sanitarians. Again the approach with sanitation work has been community oriented and stresses community management of the systems. Upgrading training for the sanitarians has continued over the years. Vocational Training and Capacity Building As a result of the CCSDPT Education Survey conducted in 1995, which illustrated a need for and interest in vocational training on the part of Karenni refugees, IRC initiated a small program in mid IRC conducted its own more in depth survey of the needs and interests in the camps and began funding small community projects in late For more information see the Vocational Training Program Assessment report (forthcoming ). The Capacity Building program also started in late The program itself was conceived after the March 1995 Karenni - SLORC ceasefire was agreed and it appeared that the refugees might soon be returning home. At that time, a training program for community program leaders was envisaged to provide them with more skills regarding managing and funding community based programs. But the capacity building program also aims to fulfill a larger need at IRC which is more involvement from the community in initiating and managing projects. IRC feels that in order for the systems of operation and community development to remain in place after repatriation and even for day to day work in the refugee camps, that a program focusing on training leaders in these topics is essential. IRC Assistance in the Northern Karen Camps: Between 1992 and 1995, IRC worked with what is now the northern Karen camp population. A brief description of these projects follows: Weigyi Camp - Karenni National People's Liberation Front (KNPLF) The KNPLF is a breakaway "communist" faction of the Karenni. Because medical services on the border were split according to ethnic groups, IRC was assigned to work with this "Karenni" group. In 1994, the KNPLF signed a ceasefire with the SLORC and agreed to "return to the legal fold." The Karen National Union (KNU) then put pressure on the leadership of this group to leave their camp at Weigyi, which they did in June For those KNPLF representatives that still remain in Thailand, BP 14 is used as their base. IRC provided sanitation training and medical monitoring assistance to this camp from 1992 until

10 1994. After the K.NPLF leadership moved to BP14 in June 1994, the residents who remained then came under the jurisdiction of the Karen Relief Committee (KRC). IRC continued to assist the residents of this camp until October of 1994, when a handover to a closer medical agency was completed (see below). Baw Nya Hta - Former Camp #6 Originally the KNPP Camp #6 was located on the Salween River downstream from Weigyi camp. In 1994, the KNPP ordered all people who wanted to remain members of Camp #6 to move up to the area of Camp #5 (see Refugee Profile for further details). After approximately 200 residents of Camp #6 left for the KNPP area, 700 people still remained in the camp. IRC also provided sanitation training and medical monitoring assistance to this camp from 1992 until IRC continued medical assistance and sanitation training in this camp after the KNPP people left for another few months and then also handed this camp over to the nearby medical agency. Handing over: IRC asked another medical relief agency (Malteser Hilfdienst - MHD) to take over the care of these two camps which had become KRC administered camps for the following reasons; the distance from Mae Hong Son to the Salween river camps was too far to allow for adequate supervision and monitoring of the situation, because the above camps had come under the control of the KRC, IRC felt that it was more efficient for the agency in the area, who already had communication with the KRC to continue the work in the area. there was another medical relief agency already based in the area willing to take the camps over. The handover of provision of supplies, supervision and monitoring of these camps to MHD was completed in late However, because IRC and MHD had a good working relationship and because IRC received increased funding in 1994, a continued cooperation in the areas of sanitation training, immunization implementation and training, community health education training and family planning implementation and training was agreed. These projects should have continued in this area throughout 1995 and However, two key incidents led IRC to withdraw; a). The fall of the Karen resistance capital ofmanerplaw and the reconfiguration of the camps in the area, meant that many of the projects were delayed until late b). The coordinator of the MHD program with whom the arrangement had been made left the program and unfortunately,~his successor would not agree to outside agency involvement in "their area." IRC has continued to assist MHD with access to vaccines for immunization and supplying health education materials, but since assisting MHD with emergency relief after the fall ofmanerplaw,

11 involvement in this region has ceased. IRC Personnel The number of personnel has expanded during the five years of operation as have the numbers of refugees that we serve. The following is a general list of the positions we have had, when they started and who they are staffed by;

12 Personnel: (by year end) 1992: Coordinator (ex-pat) Sanitarian (ex-pat) Health Educator (local) Primary Health Care Supervisor (ex-pat joined late 1992) 1993: Coordinator (ex-pat) Sanitarian (ex-pat) Health Educator (local) Primary Health Care Supervisor (ex-pat) 1994: Coordinator (ex-pat) Sanitarian (ex-pat) MCH Program Manager (local- changed job September 1994) Clinical Health Manager (ex-pat joined November 1994) Administrator (local joined January 1994) Laboratory Technician Trainer (local- Joined November 1994) 1995: Coordinator (ex-pat) Sanitarian (ex-pat) MCH Program Manager (local) Clinical Health Manager (ex-pat) Laboratory Technician Trainer/Immunization Program Assistant (local - changed Septembe 1995) Administrative Referral Officer (local- changed January 1995) CHE Program Manager (ex-pat - Joined January 1995)- Health Liaison Officer (ex-pat -joined June 1995) Administrative Assistant / Translator (local -joined January 1995) Driver (local -joined August 1995) 1996: Coordinator (ex-pat) Sanitarian (ex-pat) MCH Program^anager (local) Clinical Health Manager (ex-pat) Laboratory Technician Trainer (local) Administrative Referral Officer (local) CHE Program Manager (ex-pat) Health Liaison Officer (local -joined August 1996)

13 Administrative Assistant / Translator (local) Driver (local) Maid (local - joined January 1996) Tuberculosis Program Assistant (local -joined November 1996) Medic Trainer - (ex-pat -joined December 1996) Capacity Building Program Manager (ex-pat -joined October 1996) Karenni Intern (1) - (refugee -joined October 1996) Karenni Intern (2) - (refugee -joined October 1996) Karenni Intern (3) - (refugee -joined October 1996) Karenni Intern (4) - (refugee -joined October 1996) Relations with the Royal Thai Government (Local Level): At the outset of the program, very few formal relations were required with the local Thai government. Required coordination was primarily for the purposes of visa renewal for expatriate staff and for reporting purposes. Slowly over the years, the Thai government has formalized its role regarding the administration of relief and aid to the refugees and its work with the NGOs in the province. The IRC office is located in the provincial capital and as such we have maintained contact with the following Thai governmental and military authorities; The province: The Provincial Governor: Deputy Governor: Level of Contact: Courtesy calls, coordination regarding specials events Generally the Governor has appointed one of his Deputies to take responsibility for refugee affairs. This person is usually the highest authority in the province with whom IRC has a working relationship Provincial MOI Officers: These people are IRC's closest working colleagues at the provincial level. They authorize all work in the camps and organize visa renewals for-ex-expatriate staff. The District: The District Officer IRC has had contact with District Officers in four districts during our 5 years of operation. Presently, close contact is maintained with two district offices (Muang and Khun Yuam). District Officer 's Asst: ' This person is IRC's day to day contact in the District office. He authorizes shipments of relief goods when necessary and also arranges visas for ex-expatriate staff Military Authorities Border Patrol Police Tahaan Praan This group controls most of the area along the border where the refugees are located and mans the checkpoints that allow access to the camps. This special elite military unit is stationed in areas of conflict and is sometimes called to take control of an area in emergencies.

14 Their coordination center for MHS province is through Task Force 35 in Mae Sariang (and through the Third Army in Phitsanalok) (G.O.R.M.N) - ISOC Other: Provincial Public Health Srisangwan Hospital Malaria Center Prime Minister's Office IRC has less contact with the Internal Security Operations Center than before. This group was formed in the 1970's to counter Communist insurgency in Thailand and is still active in Mae Hong Son. Their leader in the Province is also the Deputy Governor for Military Affairs. IRC coordinates with this office for immunization supplies and control of endemic diseases in the area. Sometimes training materials are also borrowed from them. This is the provincial government hospital and the only hospital in Muang District. All Karenni patients are referred to this hospital in life-threatening and emergency cases. IRC coordinates with the malaria center for supplies, annual house spraying and in cases of emergency. Generally though, because the Thai Public Health's treatment protocol for malaria is not effective in the areas that the refugees live, other advice and coordination is sought from the Shoklo Malaria Research Unit. There is a local intelligence officer connected to the Prime Minister's office (and perhaps also the National Security Council), who assists IRC with permissions for refugees to travel and sometimes acts as an intermediary with the provincial authorities when there is a conflict. -Overall, IRC's relations with the local government authorities are very good_the largest frustration in working with them is the frequent turnover of government officers and the lack of coordination between their offices. Often IRC is asked by each agency and even by people from within each agency for the same information repeatedly. While this is a minor irritation, the continued good working relationship it promotes is essential for on-going work in this region.

15 Program Support: Donors The Burma Border Program has had strong support from a number of donors over the five years of the program. They are listed here in order of importance. For further information about the amounts of support and specific donor relations - see the Proposal and Donor Reports files. Bureau of Population, Refugees and Migration Affairs (BPRM) - US State Department (1992- ) United States Agency for International Development (USAID)3 - ( ) Bureau of Democracy, Human Rights and Labor (DRL)4 - ( ) Stri ding Vluchteling - (Netherlands) ( ) Lutheran World Relief - (American) ( ) Refugees International (Japan) (1993 -) Mellon Foundation (American) ( ) Dorothy H. Ross Foundation ( ) UNICEF - (1996) Liechtenstein Development Service ( ) USAID was the agency appointed to disperse the funds from the first US Congressional earmark for Burma. DRL was the agency appointed to disperse the funds from the second US Congressional earmark from Burma.

16 The Refugee Profile; Background: The Karenni refugee population come predominantly from Kayah (Karenni) Slate inside Burma. They are largely from the mountainous area east of the capital ofloikaw between the Pon and Salween rivers or from east of the Salween river (see attached maps). A few of the residents in the refugee camps also come from Shan State and Karen State in Burma. While most of the people in the camps identify themselves as ethnically Kayah (75%), there are more than ten different ethnic groups represented in the camps. Only a small minority of people come from urban areas and most of the population were upland farmers prior to becoming refugees. The Karenni State's geography is very mountainous with abundant natural resources including teak, rubies, marble and other minerals. In the past the Karenni National Progressive Party (KNPP) traded many of these natural resources with Thailand to support their war against the central Burmese government. Almost all trading activity has ceased since June of The source of the conflict between the Karenni and the Burmese military government (and every central government since 1948) is the Karenni contend that they are an independent, sovereign state; a state which was never part of Burma, never part of colonial Burma, and should not be a part of Burma today. The KNPP is the provisional government which represents the Karenni people in exile. For more information about the Karenni State and the Karenni political history, please see Karenni Provisional Government Manifesto and Karenni History or The Karenni Case Studies (April 1993). While the KNPP has had bases on the Thai-Burmese border for more than 20 years, it was not until 1989 that civilians from Karenni State and family members of the KNPP were forced to take refuge in Thailand. This influx was due to a State Law and Order Restoration Council (SLORC) offensive aimed at eliminating ethnic minority resistance to the central Burmese government. Other causes of refugee flows over the years have been massive forced relocation programs (1989, 1996), village harassment by SLORC soldiers, villagers being forced to work as porters and other human rights abuses. Karenni Ministerial Structure and Relief: The KNPP government is democratically elected every four years by the members of the party.5 The most recent elections were held in 1992 and at the end of The Prime Minister, who is directly elected based on the majority number of direct votes appoints his cabinet of Ministers from other senior leaders. The President, who is a nominal leader is also appointed by the Prime Minister. The KNPP party base however is very small (estimated 500) and only "full" members of the party are allowed to vote.

17 Prior to the 1996 election, there were four main ministries, which the relief agencies and other outsiders had their primary contact. They were; The Foreign Minister: The Foreign Office is the main contact point for Karenni leaders and refugees with the outside world, but at a primarily political level. Generally courtesy calls are paid to the Foreign Minister, to gain further contact with the Karenni. (Current Minister: Mr. Abel Tweed.) The Minister of the Interior: This ministry was responsible for all aspects of health, relief and administration of the refugee camps, as well as areas inside Karenni State under the auspices of the KNPP. In practice, matters pertaining to relief and health were handled by the Minister's assistant who held the concurrent positions of Director of Health and Chairperson of the Karenni Refugee Committee (Current Minister: Shia Reh - please see below for further details of restructuring). The Information Minister: The Education Minister: The Information Department is responsible for disseminating information about the Karenni people's and refugee's situation to the outside world and is very important in terms of collecting information about the Karenni situation particularly inside Karenni State. (Current Minister; Khu Oo Reh.) This minister is responsible for supporting and administering all Karenni schools (both in the refugee camps and in areas controlled by the KNPP inside Karenni state) and is the prime source of information about education. In the years between 1992 and 1996, there were a number of Education Ministers, concluding with Saw Yoshia for the last year in sec below for details on restructuring as a result of the election. In this structure, IRC worked predominantly with the assistant to the Minister of the Interior, as did most other relief agencies. In addition, those agencies interested specifically in education, also worked with the Minister of Education. As a result of the 1996 elections, two new Ministries have been created which will take the bulk of the Health and Relief work away from the Interior Ministry. These ministries are; The Minister of Health and Education: This ministry will be responsible for all programs related to Health and Education in llic camps and inside Karenni Stale. I t appears that these program will be handled predominantly through the Deputies for Health and for Education respectively for the refugee

18 camps. Because the ministry is still new as of this writing, this structure may change (Current Minister: Saw Yoshia). The Minister for Relief This new ministry has been created in the wake of the 1996 and Religion: election. Because there has been no contact with the Minister as of this time, how this ministry will work is as yet unknown. Generally, IRC consults the ministers and their deputies to keep them briefed about the health situation in the camps and to solicit their feedback on new initiatives and problems encountered. Because the ministers are considered to be very senior officials, day to day implementation of projects is generally carried out with the Deputies and the Medical Supervisors of each area. In the future it is hoped that more involvement from the ministerial leaders will be forthcoming in projects implemented by IRC. Camp Administration: Each camp has its own camp committee which is comprised of a camp administrator (in larger camps), a camp commander and section leaders. The camp administrators and camp commanders are appointed by the Karenni Minister of the Interior and the section leaders are appointed by the camp administrators and camp commanders. These camp committees are almost entirely male in make-up and many of the leaders are former village headmen or school headmasters. Many of the camp committee people are also KNPP party members. Officially they are overseen by the Karenni Minister of the Interior, but in practice, unless they live in the vicinity of the Minister, they do not have much direct oversight. The camp committees are responsible for distributing all relief goods donated to the camps, for registering new arrivals, births and deaths, for approving new projects being implemented in the camps, for physical infrastructure in the camps and for resolving any internal disputes or problems. IRC has close contact with the camp committees in each camp and holds meetings, both formal and informal with them regularly. In the case that IRC is starting a new project or initiative, the camp committees in each camp will be consulted extensively. Health: Each camp has its own clinic and refugee health workers. These health workers provide all primary curative and preventive care and health education for the camp residents. Overall, the health situation in the camps has been relatively good, with the main causes of morbidity being malaria, acute respiratory infections and diarrhea. When a camp population is stable and settled in one location for a period of time, the overall health situation improves (stable, low morbidity and mortality rates), but frequent camp movements and new arrival influxes into camps have shaken camp'health systems, especially during 1995 and More detail about the health program, how it is administered and run is provided in the Program History section of this paper.

19 Education: Within the refugee population, the level of formal education is fairly low. In two surveys conducted in 1995 and 1996, the level of formal education among the refugees was found to be as follows; Table 1: Percentage Distribution of Highest Level of Completed Education by Age and Sex (Sources: Educational Assessment of the Mon and Karenni Refugee Camps on the Thai/ Burma Border - Draft August 1995 and IRC - HIV/ AIDS Survey December 1996 ) 1995 Male Male Male Male N Female Female Female Female N No Std. Std. Std9+ No Std. Std 5-8 Std. 9+ Educa Educa- 1-4 tion tion Total Total This table clearly illustrates that levels of formal education are low throughout the population and that women are far less likely than men to have anyjbrmal education. The reason for the difference between 1995 and 1996, is the large influx of refugees during the latter year and their particularly low level of formal education. When the data is further dissected by age, it is found that people under 30 have the highest levels of educational achievement. The schools in the refugee camps are run by the KNPP Ministry of Health and Education. These schools receive an annual distribution of school supplies (notebooks, pens, pencils, erasers and rulers for each student) from the Burmese Border Consortium. Other supplies are given on an as needs basis through written requests to donors and the Karenni have found support independently for textbook production, intensive English courses, teacher training, and other projects. IRC has only supported sanitation related supplies for the schools (including water boiling kits and drinking pots) and a small school health education program in IRC's involvement with the Karenni schools is likely to increase during 1997, since the Royal Thai Government's Ministry of the Interior has provided a mandate for education assistance to refugee schools.

20 Religion: According to the Educational Assessment Survey results cited above, the breakdown of religious affiliation in the camps prior to the 1996 influx was 33% Roman Catholic, 33% Protestant, 17% Buddhist, 15% Animist and 2% with no religion. Again, this breakdown is likely to have shifted in terms of percentages with the newly arrived people, reflecting a larger Animist population. For more details about the religion of the new arrivals, please see Sandra Dudley's report (February 1997). Baptist and Roman Catholic churches are very much in evidence in the camps and are wholly supported by the community and by donations from local and overseas churches. The Karenni Camps - Population, Moves and Locations: Population: The Karenni refugee population is very young with 45% of the residents being less than 15 years old. While this is common for many refugee populations, what is uncommon with the Karenni is that there is nearly gender parity within the refugee population. This reflects that most of the families in the camps are complete units rather than a predominant number of female headed households. More information about the refugee population breakdown by gender is available from the Karenni Refugee Committee Monthly report. For the total population in the Karenni camps, please refer to Table Two below. Table 2: Karenni Refugee Population by Year End Year # of Family <1 year 1-5 years 5-15 years > 15 years Total Dec * _514 Dec * Dec Dec Dec Novl *- indicates the population from age No specifics are available for these years. Camp Locations and Moves: The Karenni camps are all located in Thailand's Mae I-long Son province which is in the northwest comer of Thailand. All of the camps are also located within a few kilometers of the border. During the past five years each camp has had to move a number of times to flee SLORC

21 offensives, to comply with Thai government consolidation/relocation policies and in some cases due to contlict with neighboring Thai villages. This section provides some context to the history of the camp's movements and the current situation in each camp. Camp #1 - Bang Yon This camp was located on the Thai-Burmese border at the demarcation point between Karenni State and Shan State. In that area, Shan State was controlled by the former Muang Tai Army leader Khun Sa. His troops could be seen on the highest mountain in the region which was totally denuded except for the bamboo outpost on the top.6 Camp #1 was a small camp of approximately 600 people, most of whom were ethnically Shan or Pa-Oh. The Shan lived in the upper section of Bang Yon and most of the Pa-Oh lived in the lower section (30 minute walk) called Huay Nam Rin. They had two school, two Buddhist temples (one in each section) and one clinic located in the upper section. The Karenni had a military base directly adjacent to the camp on the Burmese side of the border. The residents of this camp stayed in this location for almost seven years (since June 1989) and some refugees were able to obtain Thai government blue "up-land" resident cards through neighboring Thai villages. In July 1995, the situation changed when the presence ofslorc troops in the vicinity of their camp forced the residents of Camp #1(located at that time at Na- On) to move up to Camp #1. Although the residents of Camp #2 only stayed one month in Camp #1, due to continued threat from SLORC soldiers and their vulnerable position on the border, this camp was split into three sites in November The majority of people from the Pa-Oh section (Huay Nam Rin) left the camp and went to hide in the Thai jungle near the Thai village ofna Ba Paek. They have a tacit agreement with the local Thai authorities that they can stay there and are still there today. About half of the Shan residents moved to the nearby Thai village of Huay Mue Khe Som and are still there today. The other half joined Camp #2 (see below). Camp #2 Of all of the Karenni camps, Camp #2 has the longest history of moves and troubles and suffered especially between June 1995 and June The locations of their camp and the dates and circumstances of their moves are detailed below The first move to Cha Leh: Prior to the 1989 SLORC offensive, the residents of Camp #2 lived just across the border inside Burma in a small valley called Na-On, Na-On is located approximately 40 minutes walk from Camp #1 and is inside Burma. During the SLORC After Khun Sa's surrender to the SLORC in January 1996, this mountain top outpost was taken over.by the Burmese Army.

22 offensive in 1989, the residents of this camp fled to a valley at the foothills of the mountains that form the border between Thailand and Burma. This location, called Cha-leh is located approximately 40 minutes walk from the Thai village of Mai Sa Pae. In the vicinity of Cha-leh there are a number of small villages which contain mostly Karenni villagers who have lived in this area of Thailand for as long as 20 years. The Thai authorities claim that Cha-Lch is a watershed/water source area for the Thai village ofnai Soi and are never very happy about the refugees staying there. Early The return to Na-On: The Thai authorities ordered the residents of Camp #2 at Cha Leh o t move, because their location was a watershed area and they were cutting too many trees. Because no other territory was offered to them in Thailand and because it was a relatively peaceful time in Karenni State, they returned to the place called Na-On. In July 1994, the Thai authorities no longer allowed IRC physical access to the camp and its 1500 residents. IRC continued to send medical and relief supplies o t the camp, but was only allowed access once during the next 15 months when there was a measles outbreak (see the report - Measles Outbreak in a Kayah Village for further details). July The move to Camp #1: SLORC troops took control of the former Karenni market town ofmae Yu in Burma and were closing in on Na-On. The refugees moved to Camp #1 for safety. August 1995: Because of the cramped conditions in Camp #1, residents of Camp #2 moved to an interim site approximately one hour's walk from Camp #1. The new camp was located on a mountain ridge which was difficult to access and insecure. November-December 1995: Because the SLORC troops were now even closer, the residents of Camp #2 moved back to their old location in Cha Leh and re-established their camp. March 1996: SLORC launched a major offensive against the remaining KNPP troops in the area and managed to take control of the border in the vicinity of Camp #2. Prior to this offensive, 500 new arrivals from Karenni State crossed the border and joined the camp. The refugees, who were within shelling range of the border fled over the next hill to rice fields belonging to a Thai village called Huay Pong -On. After three weeks, the local Thai provincial authorities ordered the refugees relocate to the area near the old Camp #3 (see below). This site was considered insecure and no preparations had been made for the relocation. The refugees decided to move back to Cha-leh, hoping that they would be allowed to stay there. However, the Thai authorities remained firm and at the end of March 1996, the refugees were forcibly relocated. Ban Khwai and Ban Tractor: The refugees reluctantly re-established their camp in the area just below the site of the old Camp #3. They are currently located here in the mountains and narrow valleys surrounded by government forest. While they are now accessible by road, security has been and remains an issue for these people.

23 In May of 1996, the SLORC started issuing relocation orders for all villages between the Pon and Salween rivers in Kayah State. Almost 100 villages and an estimated 50,000 people were affected by these orders. In June of 1996, the first new refugees began to arrive in Camp #1. They were the first of almost 5000 who would arrive in the camp between June and November, taking the camp population to almost 7000 at the end of Most of the new arrivals are ethnically Kayah and are the people who stayed in or near their villages through all of the previous Burmese army offensives and until now had never chosen to become refugees. Their influx into the camps indicates that the situation inside Karenni State is the worst it has been in 40 years. IRC facilities had to be totally revamped to deal with the influx and new training in nearly every medical area started in order to re-balance the medical staff to patient ratio. Early 1997: In the early morning of January the 3rd, 40 armed SLORC troops came through the Thai checkpoint at the border, walked past the Ban Khwai section and attacked the upper part of the Ban Tractor section of the camp. Two refugees were killed and nine injured in the attack. Since this time, the Thai's have increased security for the camp, but the residents remain frightened of further attacks, even though they are almost four kilometers inside Thailand. The camp today has two clinics, two primary schools and one middle school, two nursery schools and two churches (one Roman Catholic and one Baptist) as well as one Buddhist temple. Camp #3: Nai Soi Many times over the years, Camp #3 has shuffled back and forth between its current location next to the Thai village of Nai Soi and the border where Camp #2 is currently located. Originally in 1989 when the refugees first crossed into Thailand, they moved to the current location of Camp #2, Ban Tractor section. Then in 1992, when SLORC again attacked the border and actually came into Thailand as far as the Ban Tractor section of Camp #2, the refugees fled to their present location near Nai Soi. After staying there for almost two years, in 1994 they chose to move back closer to the border at a site called Baan Mai. They moved after a refugee woman was raped and murdered by Thai villagers close to the camp and after a number of other small incidents between the camp youth and the Thai youth. After staying in Baan Mai for aver a year, another SLORC offensive was launched in June 1995 sending them back to their former location near Nai Soi, with about 500 new arrivals who were also fleeing the SLORC offensive on the border. They are currently residing in the Nai Soi camp location. The population of this camp is just over 2000 people. One section of Camp #3 called the "handicapped section" never moves. This section o-f-the camp, which is directly across the river^rom Nai Soi village is predominantly inhabited by ex- KNPP army soldiers who have lost a limb during fighting with the SLORC. Their families also stay with them in this section of the camp. It would seem that a deal negotiating the permanent stay of residents of this section has been agreed between the KNPP military and the local Thai authorities. There are approximately 65 houses in this section of the camp.

24 The main body of Camp #3 has one primary and middle school, one nursery school, one clinic, two churches (Roman Catholic and Baptist) and the women's group runs a weaving center. Camp #4: Huay Nam Rin Camp #4 is the smallest Kareimi camp (population 200) and for many years now has had the relative advantage of not having to move or being adversely affected by SLORC offensives. The camp was formed in its current location in It is located near the Thai village of Huay Chang Lek on the border between Muang and Khun Yuam Districts in Thailand. It is not accessible by road, but is only half an hour away from the road and is located near a Thai- Karenni village. The residents of Camp #4 are predominantly Kayah and live in much the way that they might have inside Karenni State. Their camp is well organized and clean and they have a small primary school and a small clinic. Villagers from local Thai villages also patronize the clinic. There has been some discussion on the part of the provincial Thai authorities about consolidating the residents of Camp #4 into a larger Karenni camp. This discussion follows the 1995 Thai National Security Council's decision that refugee camps should be consolidated to improve control and administration of the refugees. There seems to have been no final decision as of this date. Camp #5 Mae Surin: Camp #5 (population 1300) was formerly located on the Pai River, downstream from the Thai- Karenni village of Huay Bu Kae. However, at the end of 1992, due to an impending SLORC offensive, the residents were forced to take refuge in their current location at Mae Surin. The camp today is located on the flood plain of the Mae Surin River, which runs through-and around the camp. In a particularly bad rainy season during 1994, the camp was flooded and many of the buildings were washed away. Although the camp was re-built, many of the newer houses in the _ camp have relocated in the flood zones again. Since relocating to this area, the camp (which is almost 10 kilometers inside Thailand) has been quiet and safe. It has been designated as a permanent site for Karenni refugees in Mae Hong Son province by the local office of the Thai Ministry of the Interior. The camp contains the only Karenni high school in all of the refugee camps, two churches (Roman Catholic and Baptist), one clinic, on nursery school and a temporarily closed weaving center. Camp #6-^Baw Nya Hta: Karenni Camp #6 was originally located on the Salween River across from Karen State. The residents of the camp were predominantly Karen and came from District #2 inside Karenni Stale. After the Karenni National People's Liberation Front (KNPLF) signed a ceasefire with the