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Stanford Affiliate, Stanford Center on China's Economy and Institutions
Clinical Assistant Professor, Medicine - Infectious Diseases
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John Openshaw is an instructor in infectious diseases at Stanford University.

He is interested in the intersection between infectious disease and ecology and much of his current research is on detecting emerging zoonotic pathogens.

Zoonotic disease represents a major burden to human health: from the bubonic plague of the middle ages, to the 1918 flu pandemic that infected one third of the world’s population, to the modern Human immunodeficiency virus (HIV) epidemic which affects 34 million people living today.

His current work aims to detect viral spillover events from animals to humans with the hope of eventually understanding the ecology that drives this process and better defining the steps that will be required to stop the emergence of these pathogens.

He is also interested in the use of technology and media to improve healthcare.

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Stanford Affiliate, Stanford Center on China's Economy and Institutions
Clinical Associate Professor, Pediatrics
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Xin She is a Global Health pediatrician with 15 years of experience working in low-resource settings. She speaks 5 languages and is committed to creating interdisciplinary, equitable solutions for all vulnerable children to thrive. She is a national representative at the Women Physicians Wellness, Equity and Leadership Alliance (WEL).

She has published on mental health epidemiology and health inequity in Chinese children, early childhood development and quality improvement in pediatric care for Haitian Children. She has presented nationally and internationally on Social Medicine and Global Health, youth mental health, early childhood development, Wellness and professional development. She has collaborated with academic, governmental and non-profit partners in inner city US, Canada, Mexico, Guatemala, Haiti, DR Congo and China.

She has mentored more than 100 youth globally, ranging from rural Chinese children, inner city American youth, to medical trainees in Haiti, at Harvard and at Stanford. She is a mentor at national programs for underrepresented minority students and for international junior researchers. She has been twice awarded the AAP national Advocacy conference scholarship and regularly advocates for underserved communities locally and nationally.

She chairs the Pediatric Wellness Committee at CPMC regional site and serves as a Wellness Champion for the department of Pediatrics. She is certified in Mindfulness-based Stress Reduction and Reiki (Master). She is also a Cordon Bleu graduate in Spanish cuisine and loves hosting friends from all over the world.

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Stanford Affiliate, Stanford Center on China's Economy and Institutions
Associate Professor of Psychiatry and Behavioral Sciences
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PhD

Dr. Singh is Associate Professor of Psychiatry and Behavioral Sciences and her multidisciplinary research investigates the neurobiology underlying mood disorders and related psychiatric conditions. Her team uses a clinical translational approach to examine neural circuit dynamics in the human brain in order to ascertain neurobiological correlates of behavior. A major focus of the research is directed to risk factors of mood disorders including genetics as well as developmental exposure and adaptation to early life and family environmental stress. Her team also conducts human clinical trials in developing novel therapies for youth onset mood disorders.

The Stanford Pediatric Mood Disorders Research Program promotes healthy brain development across the lifespan through a deeper understanding of how youth adapt to mood symptoms and stress to have successful transitions into adulthood. The program's bold vision is to prevent chronic and progressive mood disorder and to improve the mental health of children, adolescents, young adults, and families through globally recognized research, education, and innovation. The program’s research is multidisciplinary, bringing together experts from the fields of psychiatry, psychology, neuroscience, computer science, biostatistics, genetics, regulatory, and industry to seek answers for complex questions related to brain-behavior-environment relations in developing youth with and at risk for mood disorders, and to accelerate discovery of novel therapeutic strategies.

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Although eyeglasses have been considered a cost-effective way to combat myopia, the empirical evidence of its impacts on improving learning outcomes is inconsistent. This paper provides empirical evidence examining the effect of providing eyeglasses on academic performance between provinces with a different economic level in western China. Overall, we find a significant impact in Intention-to-Treat analysis and a large and significant local average treatment effect of providing free eyeglasses to students in the poor province but not in the other. The difference in impact between the two provinces is not a matter of experimental design, implementation, or partial compliance. Instead, we find that the lack of impact in the wealthier provinces is mainly due to less blackboard usage in class and wealthier households. Our study found that providing free eyeglasses to disadvantaged groups boosted their academic performance more than to their counterparts.

Authors
Kang Du
Huan Wang
Huan Wang
Yue Ma
Yue Ma
Hongyu Guan
Scott Rozelle
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Background: The importance of breastfeeding in low- and middle- income countries is well recognized, yet the importance of postnatal mental health on breastfeeding practices and beliefs in these settings has been understudied. This study investigates the associations between maternal mental health problems, breastfeeding beliefs and breastfeeding practices in rural China.

 

Methods: Cross-sectional data were collected in November and December 2019 from 742 mothers of infants under 6 months old in rural Sichuan Province, China. Maternal mental health (depression, anxiety, and stress symptoms) was assessed using the Depression, Anxiety, and Stress Scale (short form). Breastfeeding beliefs were assessed using the Iowa Infant Feeding Attitude Scale and Breastfeeding Self-Efficacy Scale (short form). Breastfeeding practices were assessed through a 24-h dietary recall questionnaire. Ordinary least squares regression, multiple logistic regression and heterogeneous effects analyses were used to identify associations between symptoms of mental health problems and breastfeeding outcomes.

 

Results: The average age of sample infants was 2.7 months. Among mothers, 13% showed symptoms of depression, 16% anxiety, and 9% stress. The prevalence of exclusive breastfeeding in the previous 24 h was 38.0%. Depression symptoms were significantly associated with breastfeeding attitude and breastfeeding self-efficacy. Anxiety and stress symptoms were significantly associated with breastfeeding self-efficacy. There were no significant associations between symptoms of mental health problems and exclusive breastfeeding. The heterogeneous effects analyses revealed that less educated mothers with symptoms of stress had lower odds of exclusive breastfeeding than educated mothers without symptoms of stress. Mothers of younger infants had higher odds of exclusive breastfeeding than the mother of older infants, regardless of depression, anxiety, or stress symptoms.

 

Conclusion: Symptoms of maternal mental health problems are significantly associated with breastfeeding attitude and self-efficacy; however, these symptoms are not associated with breastfeeding practices. Maternal educational level and infant age may play a role in mothers’ breastfeeding practices. To improve breastfeeding practices, interventions should employ a multi-dimensional approach that focuses on improving maternal mental well-being and considers demographic characteristics.

Journal Publisher
International Breastfeeding Journal
Authors
Qi Jiang
Evelyn Zhang
Nourya Cohen
Mika Ohtori
Sabrina Zhu
Yian Guo
Yian Guo
Hannah Faith Johnstone
Sarah-Eve Dill
Huan Zhou
Scott Rozelle
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Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the “know-do gap” between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future.

Journal Publisher
Frontiers in Public Health
Authors
Sha Meng
Qingzhi Wang
Yuju Wu
Hao Xue
Linhua Li
Ruixue Ye
Yunwei Chen
Lucy Pappas
Muizz Akhtar
Sarah-Eve Dill
Sean Sylvia
Huan Zhou
Scott Rozelle
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Background
High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China.

Methods
In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence.

Results
The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers’ reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups.

Conclusions
In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence.

Journal Publisher
BMC Public Health
Authors
Rong Liu
Ruixue Ye
Qingzhi Wang
Lucy Pappas
Sarah-Eve Dill
Scott Rozelle
Huan Zhou
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Global Health Economics, China, & the Science of Health Care Delivery in the Digital Age


Advances in artificial intelligence, use of "big data", digital platforms enabling mass collaboration, automation, the "internet-of-things" and other so-called "4th Industrial Revolution" (4IR) technologies are enabling a radical shift in how healthcare is delivered. Few places are attempting to integrate these technologies into healthcare as rapidly as China. This talk will discuss China's comparative advantage in the adoption of these technologies and lay out a research agenda for the economics of digital health. While these technologies bring potential to produce massive improvements in access to high-quality care and lower costs, this result is far from certain. Beyond mere technical uncertainty, 4IR technologies are likely to produce profound changes in healthcare markets by altering the nature of incentives in the health system and relationships between patients, providers, payers. Evidence on these issues is needed to inform policy and regulation aiming to maximize social value and mitigate unintended consequences. Specific applications will be drawn from online research in China and other middle-income countries.


About the Speaker

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Sean Sylvia headshot.
Sean Sylvia is an Assistant Professor of health economics at UNC. His primary research interest is in the delivery of healthcare in China and other middle-income countries. Working with multidisciplinary teams of collaborators, he conducts large-scale population-based surveys and randomized trials to develop and test new approaches to provide healthcare to the poor and marginalized. His recent work focuses on the use of information technology to expand access to quality healthcare. 


For more information, please visit his personal website.


This event will be held in-person at Stanford University, masks are not required but strongly encouraged.

Questions? Contact sccei-communications@stanford.edu


 

Philippines Room, C330, Encina Hall, Stanford University

Sean Sylvia
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Beth Duff-Brown
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The Supreme Court ruling eliminating the constitutional right to an abortion could also result in women’s personal reproductive health data being used against them, warns Stanford Health Policy’s Michelle Mello.

The Dobbs v. Jackson Women’s Health Organization ruling could, for example, lead to a woman’s health data in clinician emails, electronic medical records, and online period-tracking platforms being used to incriminate her or her health-care providers, Mello said.

“Ultimately, broader information privacy laws are needed to fully protect patients and clinicians and facilities providing abortion services,” writes Mello, a professor of health policy and law in this JAMA Health Forum article with colleague Kayte Spector-Bagdady, a bioethicist from the University of Michigan. “As states splinter on abortion rights after the Dobbs Supreme Court decision, the stakes for providing robust federal protection for reproductive health information have never been higher.”

Eight states banned abortions on the same day the Dobbs ruling came down, and 13 states that had “trigger bans” that, if Roe v. Wade were struck down, would automatically prohibit abortion within 30 days. Other states are considering reactivating pre-Roe abortion bans and legislators in some states intend to introduce new legislation to curb or ban the medical procedure.”

Three Potential Scenarios

The authors note these new abortion restrictions may clash with privacy protections for health information, laying out three scenarios that could impact millions of women. And, they note, “despite popular misconceptions about the breadth of the Privacy Rule of the Health Information Portability and Accountability Act (HIPAA) and other information privacy laws, current federal law provides little protection against these scenarios.”

The first scenario is that a patient’s private health information may be sought in connection with a law-enforcement proceeding or civil lawsuit for obtaining an illegal abortion. HIPAA privacy regulations and Fourth Amendment rights against unreasonable searches and seizures won’t help physicians and hospitals resist such investigative demands, the authors write. And though physician-patient communications are ordinarily considered privileged information, the scope of that privilege varies greatly from state to state. “In many cases medical record information has been successfully used to substantiate a criminal charge,” the authors write.

Ultimately, broader information privacy laws are needed to fully protect patients and clinicians and facilities providing abortion services.
Michelle Mello
Professor of Health Policy, Law

The second privacy concern is the potential use of health-care facility records to incriminate an institution or its clinicians for providing abortion services. Relevant records could include electronic health records, employee emails or paging information and mandatory reports to state agencies. Clinicians may not realize that if they are using an institutional email address or server, their institution likely has direct access to information and communications stored there, which can be used to search for violations. State Freedom of Information Act (FOIA) laws also allow citizens to request public records from employees of government hospitals and clinics.

“Additionally, state mandatory reporting laws for child abuse might be interpreted to cover abortions — particularly if life is defined as beginning at fertilization,” the authors note.

The third scenario is that information generated from a woman’s online activity could be used to show she sought an abortion or helped someone to do so. Many women use websites and apps that are not HIPAA-regulated or protected by patient-physician privilege, such as period-tracking apps used by millions of women that collect information on the timing of menstruation and sexual activity.

“There are many instances of internet service providers sharing user data with law enforcement, and prosecutors obtaining and using cellphone data in criminal prosecutions,” write Mello and Spector-Bagdady, adding commercially collected data are also frequently sold to or shared with third parties.

“Thus, pregnant persons may unwittingly create incriminating documentation that has scant legal protection and is useful for enforcing abortion restrictions,” they said.

The immediate problem, Mello notes, is in the states that have already banned abortion or passed restrictive laws.

“There could be a problem with states trying to reach outside their borders to prosecute people, but that could well be unconstitutional,” Mello said.

Some states’ laws sweep abortion pills into the definition of illegal abortions, she said, and there are legal obstacles to supplying the pills across state lines.

“There is a lot of energy going into figuring out a workaround right now, but it’s too soon to call,” Mello said.

Recommended Protections

So how can clinicians and health-care facilities protect their patients and themselves?

When counseling patients of childbearing age about reproductive health issues, clinicians should caution their patients about putting too much medical data online and refer them to expert organizations that will help them minimize their digital footprint.

When documenting reproductive health encounters, the authors said, clinicians should ask themselves: “What information needs to be in the medical record to assure safe, good-quality care, buttress our claim for reimbursement, or comply with clear legal directives?” For example, does information about why a patient may have experienced a miscarriage need to be recorded?

Patients and clinicians should be aware that email and texting may be seen by others, so conversations among staff about reproductive health issues may best be conducted by phone or in person.

Finally, if abortion-related patient information is sought by state law enforcement officials, a facility’s attorney should be consulted about asserting physician-patient privilege and determining whether the disclosure is mandated by law.

Michelle Mello

Michelle Mello

Professor of Health Policy, Law
Focuses on issues at the intersection of law, ethics and health policy.
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Michelle Mello writes that the overturning of Roe v. Wade — ending federal protection over a woman's right to an abortion — could also expose her personal health data in court.

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Noa Ronkin
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More than a year after Myanmar’s military junta seized power in a coup, the military’s concerted offensive operations have failed to crush anti-regime resistance forces and consolidate power in rural areas. The violent deadlock between the military government and multiple opposition groups shows no signs of easing, and the people of Myanmar remain trapped in an escalating political, economic, and humanitarian crisis.

According to the latest report from the United Nations Office for the Coordination of Humanitarian Affairs, the number of internally displaced people (IDPs) in the country has exceeded one million, basic services have collapsed, and more than 14 million people have humanitarian needs.

APARC’s Southeast Asia Program and Asia Health Policy Program bring attention to the political context of the civil conflict in Myanmar and the implications of the multidimensional crisis in the country. This past spring quarter, the Southeast Asia Program dedicated one of its webinars to examining the opportunities and challenges faced by the opponents of Myanmar’s military regime. The virtual discussion featured two experts: Nyantha Maw Lin, an analyst with extensive experience in government affairs, public policy, and political risk assessment related to Myanmar, and Scot Marciel, a career diplomat and former U.S. Ambassador to Myanmar who now serves as a visiting practitioner fellow on Southeast Asia at APARC.

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A Shifting Civil Conflict

Nyantha described the evolution of the anti-coup movement in Myanmar from its beginnings with protests and civil disobedience campaigns by government workers and civil servants to its current state of armed resistance movement aimed at bringing down the military regime. Ethnic Armed Organizations (EAOs) have played a pivotal role in this shift. These non-state actors have fought the Myanmar military for decades in the borderlands and hold parts of the country under de facto control, sheltering and training tens of thousands of young people.

These resistance groups now present a powerful front of grassroots-level insurgency that is hampering operations by the coup regime. In this collection of self-organized groups, some are working with the National Unity Government (NUG) shadow administration, others with more decentralized networks, but all share the conviction that armed struggle is the only option for dealing with the military regime.

The power dynamic between the military and anti-regime resistance forces is now existential for both sides. “We are looking at what will most likely be a protracted civil conflict in Myanmar,” says Nyantha.

What are the paths toward a better future for Myanmar? One possibility is a shift in the military’s calculus, though it would necessitate a leadership change. Another possibility, according to Nyantha, is that the array of opposition actors can come together and use multilateral platforms to facilitate unprecedented forms of cooperation beyond resistance against the military to establish areas of territorial control and self-governance. “If they can emerge from this process with a new political vision and a roadmap for a more tolerant and inclusive Myanmar, then there is a chance the balance may tip against the military.”

These platforms include the National Unity Consultative Council (NUCC), which includes representatives from multiple opposition groups. Depending on how dialogues within the NUCC continue, it could generate a new political dynamic in the country and lay the groundwork for a future federal democratic union, notes Nyantha.

 

As long as the military is in power, Myanmar is not going to enjoy peace or stability.
Ambassador Scot Marciel

Historical Grievances, Future Visions

But there remains a lot of work to do to build trust among Myanmar’s traditionally fractious ethnic groups, Ambassador Marciel stresses. This mistrust has historical roots in decades of political disunity among Myanmar’s ethnic minorities amidst struggles for autonomy and self-determination, and in their longstanding grievances toward the state that has privileged the majority Burmans (also known as Bamar). Thus, possibly the biggest weakness of the resistance movement is the lack of a unified vision for establishing civilian rule. “I do think that it is hugely important to bring about more unity to the movement that is resisting the military regime,” says Marciel.

The international community should better understand the complexity of the civil conflict in Myanmar and recognize that the spontaneous revolt underway is not only a resistance front against the military but also a movement demanding dramatic social and political change, Marciel emphasizes.

He, therefore, cautions that the traditional tools of conventional diplomatic thinking – ceasefire, peaceful negotiations, and dialogue — do not currently apply to Myanmar. “At this point, there is no realistic scenario of dialogue leading to some compromise deal. As long as the military is in power, Myanmar is not going to enjoy peace or stability.” The people of Myanmar have suffered for far too long at the hands of the military, and the resistance forces are not interested in a compromise deal that would allow the military to maintain substantial political power, Marciel says. At the same time, the military is also not interested in negotiating.

According to Marciel, the international community should focus on supporting the resistance movement efforts. He also expressed this point in a recent interview with The Irrawaddy. “[T]he best possible scenario is for the military to face so much pressure that they then begin to look for a way out […] I think that maximum pressure on the military, both internally and externally, whether it’s by sanctions or other means, is the best chance of achieving progress, though it won’t be easy.”

To fight a pandemic, collective action is needed. Instead, Myanmar has faced a collective trauma.
Dr. Phyu Phyu Thin Zaw

A Deadly Syndemic

Even before the coup, Myanmar had one of the world’s weakest health systems and one of the least prepared for addressing epidemics and pandemics, according to the 2019 Global Heath Security Index. The devastating effects of the coup have coincided with the COVID-19 pandemic, combining into a perfect storm that has brought the country’s already-fragile health system to collapse.

The coup and the post-coup conflicts interact with the pandemic and Myanmar’s fragmented health system in ways that resemble a syndemic, says Phyu Phyu Thin Zaw, a medical doctor, epidemiologist, and health systems researcher now based at the University of Hong Kong’s School of Public Health. The term syndemic refers to the synergistic nature of health and social problems affecting vulnerable communities and contributing to an excess disease burden. It helps explain the dire crises gripping Myanmar’s health system, explains Dr. Thin Zaw.

Thin Zaw, a former visiting scholar at APARC, spoke at a webinar hosted by the Asia Health Policy Program about the impacts of the devastation caused by the coup and the COVID-19 pandemic on Myanmar’s health system and the current opportunities and challenges for response and recovery. She was joined by Nay-Lin Tun, a medical doctor who manages programs that help vulnerable communities in remote and conflict-affected areas of Myanmar to get access to health services.

Since the coup, hundreds of medical personnel and health care workers have been dismissed and subject to violent attacks. Many have escaped to areas under the control of anti-junta forces, leading to a severe “brain drain” or rather “brain hemorrhage” in the health system, Thin Zaw notes. When the third wave of the coronavirus struck Myanmar in July 2021, it hit like a tsunami. Immunization plans were severely interrupted, no quarantine or contact tracing measures were taken, and with shortages of health workers, medicine, and equipment, the health system was soon overwhelmed, with thousands of infections and rising deaths.

“To fight a pandemic, collective action is needed. Instead, Myanmar has faced a collective trauma,” says Thin Zaw. “The coup destroyed the reciprocal trust both horizontally among people and vertically between people and the government.”

Challenges for Humanitarian Response

Myanmar needs humanitarian assistance in every area, but grueling challenges hamper humanitarian relief delivery. International aid groups grapple with shuttered access, high-cost and high-risk operations, and ethical and political dilemmas: Should they stay or exit? Through which channels should they deliver aid? How can they advocate and work with the military junta? How should their money be spent under the military regime?

Dr. Tun, providing a grassroots medical humanitarian perspective on what is happening in Myanmar, described the multiple problems facing providers and patients on the ground. These include a severe shortage of health workers on the frontline, difficulties getting patients to hospitals, lack of essential medical supplies and equipment, COVID-19 infections, and overall increased mortality and morbidity among IDPs. He presented the results of a mixed-methods survey of health care workers conducted in non-military-controlled areas and conveyed their urgent requests for help. 

A Way Forward

With Myanmar’s health system in collapse, this is a time to focus on strengthening primary health care and leveraging the silver lining of the post-coup softening of ethnic tensions to build a federal health education system for inclusiveness, said Thin Zaw. She pointed to the collaboration between the NUG and EAOs-controlled healthcare groups as an encouraging step towards creating a federal health system.

She urged international actors to be realistic about the limits of their influence over the military junta and to create flexible and politically sensitive aid programs with contingency plans. Yet international organizations must continue all efforts to support the delivery of critical services to the people of Myanmar, especially in areas such as food security, emergency health, and COVID-19 response, she said. “Please don’t forget the people of my country,” she pleaded.

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