It sounds so simple as to be innocuous, a throwaway line in publichealth warnings about Type A (H1N1) flu. But one of the most powerful weapons against the new virus is summed up in a three-word phrase you first heard from your mother: Wash your hands.
A host of recent studies have highlighted the importance and the scientific underpinning of this most basic hygiene measure. One of the most graphic was done at the University of California,Berkeley, where researchers focused video cameras on 10 college students as they read and typed on their laptops.
The scientists counted the times the students touched their faces, documenting every lip scratch, eye rub and nose pick. On average, the students touched their eyes, noses and lips 47 times during a three-hour period, once every four minutes.
Hand-to-face contact has a surprising impact on health. Germs can enter the body through breaks in the skin or through the membranes of the eyes,mouth and nose.
The eyes appear to be a particularly vulnerable port of entry for viral infections, said Mark Nicas, a professor of environmental health sciences at Berkeley. Using mathematical models,Nicas and colleagues estimated that in homes, schools and dorms, hand-toface contact appears to account for about one-third of the risk of flu infection,according to a report this month in the journal Risk Analysis .
In one study of four residence halls at the University of Colorado, two of the dorms had hand sanitiser dispensers installed in every dorm room, bathroom and dining area, and students were given educational materials about the importance of hand hygiene. The remaining two dorms were used as controls, and researchers simply monitored illness rates.
During the eight-week study period,students in the dorms with ready access to hand sanitisers had a third fewer complaints of coughs, chest congestion and fever. Overall, the risk of getting sick was 20 percent lower in the dorms where hand hygiene was emphasized,and those students missed 43 percent fewer days of school.
Young children benefit, too. In a study of 6,000 elementary school students in California, Delaware, Ohio and Tennessee, students in classrooms with hand sanitisers had 20 percent fewer absences due to illness. Teacher absenteeism in those schools dropped 10 percent.
Better hand hygiene also appears to make a difference in the home, lowering the risk to other family members when one child is sick. Harvard researchers studied nearly 300 families who had children 5 or younger in day care. Half the families were given a supply of hand sanitiser and educational materials; the other half were left to practice their normal hand washing habits.
In homes with hand sanitisers, the risk of catching a gastrointestinal illness from a sick child dropped 60 percent compared with the control families. The two groups did not differ in rates of respiratory illness rates, but families with the highest rates of sanitiser use had a 20 percent lower risk of catching such an illness from a sick child.
Regular soap and water and alcoholbased hand sanitisers are both effective in eliminating the H1N1 virus from the hands. In February, researchers in Australia coated the hands of 20 volunteers with copious amounts of a seasonal H1N1 flu virus.
The concentration of virus was equivalent to the amount that would occur when an infected person used a hand to wipe a runny nose.
When the subjects did not wash their hands, large amounts of live virus remained even after an hour, said the lead author, Dr M. Lindsay Grayson, a professor of medicine at the University of Melbourne. But using soap and water or a sanitiser virtually eliminated the presence of the virus.
Frequent hand washing will not eliminate risk. When an infected person coughs or sneezes, a bystander might be splattered by large droplets or may inhale airborne particles. In a recent Harvard study of hand sanitiser use in schools, hand hygiene practices lowered risk for gastrointestinal illness but not upper respiratory infections.
Still, it is a good idea to wash your hands regularly even if you're not in contact people who are obviously ill. In a troubling finding, a recent study of 404 British commuters found that 28 percent had faecal bacteria on their hands. In one city, 57 percent of the men sampled had contaminated hands,according to the study, which was published this month in the journal Epidemiology and Infection ."We were surprised by the high level of contamination," said Gaby Judah, a researcher at the London School of Hygiene and Tropical Medicine. Judah added that many of the contaminated commuters reported that they had washed their hands that morning. They may have been embarrassed to admit they hadn't washed, or they may have picked up the bacteria on their hands during their commute.
For all those reasons, the Centres for Disease Control and Prevention, with other health organisations around the world, urge frequent hand washing with soap and water or alcohol-based hand sanitisers.(They also repeat some advice you may not have heard from your mother: Cough or sneeze into the crook of your elbow, not your hands.)
And as hospitals put stricter hand hygiene programmes in place, absentee rates during cold and flu season also drop.
"Statistically, you can't determine a causal relationship, but it's very suggestive," said Neil O. Fishman, infectious disease specialist at the University of Pennsylvania.
"Our vaccination rates remained relatively stable, so what else changed? The only thing different was that hand hygiene rates increased."
Wednesday, September 23, 2009
Eid gatherings fuel fears of flu contagion
Muslims across the world celebrated Eid al-Fitr yesterday to mark the end of Ramadan, but authorities urged caution as large social gatherings and returning Mecca pilgrims fuelled fears of swine flu spreading.
In Cairo, where two people have died from the H1N1 flu virus and nearly 900 cases have been reported, preachers suggested that worshippers perform the traditional dawn prayer at home rather than at crowded mosques.
"We ought to cancel Eid prayers ...there should be a national campaign to keep crowded places clean and ensure they are safe for people," Suad Saleh, head of Islamic Jurisprudence at Al-Azhar University told the Englishlanguage Egyptian Gazette .Cairo airport authorities have reinforced swine flu testing measures as the end of Ramadan means the return of thousands of pilgrims from Saudi Arabia.
Fear of the virus spreading in the crowded conditions during the pilgrimage is shared by many other countries who are considering cancelling the annual Hajj pilgrimage this year.
Jordanians have been urged to refrain from kissing each other in a bid to combat the contagious disease.
"People should not kiss at social events and gatherings. Instead, they should just shake hands," the government's fatwa department said in a statement ahead of the Eid holiday.
In Jakarta, thousands of people queued for hours outside the presidential palace to pay their respects to President Susilo Bambang Yudhoyono.
Indonesian officials fearful of the spread of swine flu set up thermal scanners at the open house event, which is part of a tradition whereby people throughout the country ask forgiveness from others for slights and offences.
In the world's largest Muslimmajority country, nearly 30 million people were estimated to have emptied out of cities and towns in a yearly exodus to celebrate the holiday.
The Transport Ministry said 184 people have died in the traffic chaos already.
The start of Eid is traditionally determined by the sighting of the new moon, often dividing rival Islamic countries and sects over the exact date.
In Iraq, Shi'ites loyal to the Grand Ayatollah Ali Husseini al-Sistani, the nation's top Shi'ite cleric, continued fasting yesterday, observing nationally televised and locally delivered messages that the new moon had not yet risen.
However those who follow the Shi'ite cleric Moqtada al-Sadr ended the holy month of Ramadan early yesterday.
Iraq's minority Sunnis ended Ramadan on Saturday.
In neighbouring Iran, politics overshadowed prayer, with supreme leader Ayatollah Ali Khamenei taking aim at Israel, Western powers and the foreign media. In his sermon, Mr Khamenei said a "Zionist cancer" was gnawing into the lives of Islamic nations.
In Afghanistan, President Hamid Karzai extended an olive branch to Taliban militants trying to overthrow his Western-backed government.
"On this auspicious day once again I ask all those Afghan brothers who are unhappy or are in others' hands to stop fighting, destroying their own land and killing their own people," he said at the presidential palace in Kabul."They must come to their houses and live in peace in their own country."
Pakistani families uprooted by conflict with the Taliban face a miserable Eid, with no cash to splash on celebrations and desirous of returning to homes they fear no longer exist.
The UN said about two million Pakistanis were displaced as a result of fighting between the army and Taliban militants.
Meanwhile, residents of restive Indian Kashmir jammed markets in defiance of a rise in militant violence to stock up for Eid.
The festival to celebrate the close of the holy month will be held Monday or Tuesday, depending when the new crescent moon is sighted in the restive Himalayan region where Islamic militants have been fighting against New Delhi's rule for 20 years.
Shopkeepers set up extra kiosks to cater to the mad shopping rush.
Muslim separatists who are leading the movement to break away from India and join Pakistan, or declare an independent state, called on followers to show austerity.
In Cairo, where two people have died from the H1N1 flu virus and nearly 900 cases have been reported, preachers suggested that worshippers perform the traditional dawn prayer at home rather than at crowded mosques.
"We ought to cancel Eid prayers ...there should be a national campaign to keep crowded places clean and ensure they are safe for people," Suad Saleh, head of Islamic Jurisprudence at Al-Azhar University told the Englishlanguage Egyptian Gazette .Cairo airport authorities have reinforced swine flu testing measures as the end of Ramadan means the return of thousands of pilgrims from Saudi Arabia.
Fear of the virus spreading in the crowded conditions during the pilgrimage is shared by many other countries who are considering cancelling the annual Hajj pilgrimage this year.
Jordanians have been urged to refrain from kissing each other in a bid to combat the contagious disease.
"People should not kiss at social events and gatherings. Instead, they should just shake hands," the government's fatwa department said in a statement ahead of the Eid holiday.
In Jakarta, thousands of people queued for hours outside the presidential palace to pay their respects to President Susilo Bambang Yudhoyono.
Indonesian officials fearful of the spread of swine flu set up thermal scanners at the open house event, which is part of a tradition whereby people throughout the country ask forgiveness from others for slights and offences.
In the world's largest Muslimmajority country, nearly 30 million people were estimated to have emptied out of cities and towns in a yearly exodus to celebrate the holiday.
The Transport Ministry said 184 people have died in the traffic chaos already.
The start of Eid is traditionally determined by the sighting of the new moon, often dividing rival Islamic countries and sects over the exact date.
In Iraq, Shi'ites loyal to the Grand Ayatollah Ali Husseini al-Sistani, the nation's top Shi'ite cleric, continued fasting yesterday, observing nationally televised and locally delivered messages that the new moon had not yet risen.
However those who follow the Shi'ite cleric Moqtada al-Sadr ended the holy month of Ramadan early yesterday.
Iraq's minority Sunnis ended Ramadan on Saturday.
In neighbouring Iran, politics overshadowed prayer, with supreme leader Ayatollah Ali Khamenei taking aim at Israel, Western powers and the foreign media. In his sermon, Mr Khamenei said a "Zionist cancer" was gnawing into the lives of Islamic nations.
In Afghanistan, President Hamid Karzai extended an olive branch to Taliban militants trying to overthrow his Western-backed government.
"On this auspicious day once again I ask all those Afghan brothers who are unhappy or are in others' hands to stop fighting, destroying their own land and killing their own people," he said at the presidential palace in Kabul."They must come to their houses and live in peace in their own country."
Pakistani families uprooted by conflict with the Taliban face a miserable Eid, with no cash to splash on celebrations and desirous of returning to homes they fear no longer exist.
The UN said about two million Pakistanis were displaced as a result of fighting between the army and Taliban militants.
Meanwhile, residents of restive Indian Kashmir jammed markets in defiance of a rise in militant violence to stock up for Eid.
The festival to celebrate the close of the holy month will be held Monday or Tuesday, depending when the new crescent moon is sighted in the restive Himalayan region where Islamic militants have been fighting against New Delhi's rule for 20 years.
Shopkeepers set up extra kiosks to cater to the mad shopping rush.
Muslim separatists who are leading the movement to break away from India and join Pakistan, or declare an independent state, called on followers to show austerity.
Poor "have no access" to vaccine
Top of the agenda for the World Health Organisation's (WHO)Western Pacific meeting this week will be how to combat the H1N1 flu pandemic in developing nations.
There are growing fears that poorer countries will not get enough vaccines,despite a pledge last week by the US and eight other nations to make 10% of their flu vaccine supply available to others in need.
"The developing world will have no access to vaccines for the time being.There are some donations but it is not enough," said Lo Wing-lok, a member of Hong Kong's government scientific committee on emerging diseases.
"It is very much a matter of equity and the WHO must look at any way to address this."
Developing countries such as the Philippines are not only unable to produce the vaccine for the H1N1 flu virus but their people are more vulnerable to infection because of poverty, crowded living conditions and lack of healthcare.
While the Americas still have the highest death toll from the virus, cases are expected to increase.
In the Western Pacific there are about a million people living in poor conditions without access to healthcare, making them particularly vulnerable, WHO regional director Shin Young-soo said yesterday, on the eve of the WHO meetings in Hong Kong.
"Hopefully many countries including China and the United States are soon going to vaccinate their own people but that is not the case for many developing countries and it is something we are worried about," he said.
The WHO and the UN are working on raising a billion dollars to help buy vaccines for countries that need help,he added.
Mr Shin said some experts estimate that 20% to 30% of the Western Pacific region will eventually be affected by the virus. So far Australia has the highest H1N1 flu death toll in the region, with about 171 deaths, according to the WHO.
The organisation warned last week that production of vaccines will fall substantially short of the amount needed to protect the global population.
The WHO put the number of deaths worldwide from the virus at 3,486, up 281 from the previous week.
Despite new evidence that only one dose of the vaccines currently being tested will be enough for most people,a WHO spokesman said output next year will be "substantially less" than the annual 4.9 billion doses production forecast. The US, Australia, Brazil, UK, France,Italy, New Zealand, Norway and Switzerland have said they will make donations to nations without vaccines.
There are growing fears that poorer countries will not get enough vaccines,despite a pledge last week by the US and eight other nations to make 10% of their flu vaccine supply available to others in need.
"The developing world will have no access to vaccines for the time being.There are some donations but it is not enough," said Lo Wing-lok, a member of Hong Kong's government scientific committee on emerging diseases.
"It is very much a matter of equity and the WHO must look at any way to address this."
Developing countries such as the Philippines are not only unable to produce the vaccine for the H1N1 flu virus but their people are more vulnerable to infection because of poverty, crowded living conditions and lack of healthcare.
While the Americas still have the highest death toll from the virus, cases are expected to increase.
In the Western Pacific there are about a million people living in poor conditions without access to healthcare, making them particularly vulnerable, WHO regional director Shin Young-soo said yesterday, on the eve of the WHO meetings in Hong Kong.
"Hopefully many countries including China and the United States are soon going to vaccinate their own people but that is not the case for many developing countries and it is something we are worried about," he said.
The WHO and the UN are working on raising a billion dollars to help buy vaccines for countries that need help,he added.
Mr Shin said some experts estimate that 20% to 30% of the Western Pacific region will eventually be affected by the virus. So far Australia has the highest H1N1 flu death toll in the region, with about 171 deaths, according to the WHO.
The organisation warned last week that production of vaccines will fall substantially short of the amount needed to protect the global population.
The WHO put the number of deaths worldwide from the virus at 3,486, up 281 from the previous week.
Despite new evidence that only one dose of the vaccines currently being tested will be enough for most people,a WHO spokesman said output next year will be "substantially less" than the annual 4.9 billion doses production forecast. The US, Australia, Brazil, UK, France,Italy, New Zealand, Norway and Switzerland have said they will make donations to nations without vaccines.
Monday, September 21, 2009
Migrant health care a critical issue
In Tak province, caring for migrant workers and their families is straining the provincial hospital toits limits, while in some border provinces many apparently go without needed treatment By Erika Fry
When Mae Sot General Hospital first ran out of space a few years ago,hospital staff pitched tents and dragged out old beds. Since then, the problem hasn't improved - the crowded conditions have become more frequent and new beds have been permanently stationed in the hospital corridors. They are seldom empty.
But beds are hardly the extent of the hospital's resource problems. The hospital has a skeleton staff of five Burmese migrants serving as health workers and translators who assist Thai health personnel, but because of labour regulations they are technically employed as domestic workers. The Ministry of Labour limits migrant workers to low-skill work in the agricultural, manufacturing, fisheries or domestic sectors.
The waiting room is invariably crowded,and hospital personnel are overworked. Last year the hospital ran a 50 million baht deficit.
The reason for this debt is well known,and a subject on the minds of hospital administrators, public health officials, NGO staff and a number of Thai patients who ask their doctors why they must treat patients from Burma - the rising cost of providing health care to Mae Sot's migrant population.
Dr Patjuban Hemhongsa, chief medical officer for Tak province, home to Mae Sot and 30 formal points of entry on the ThaiBurma border, looked exasperated when asked about the issue. He called Tak "a perfect place for so many problems we can't solve refugees, stateless, displaced persons and a continuous flow of illegal migrants. There is no budget or system to care for them".
Dr Supakit Sirilak, director of the Bureau of Policy and Strategy for the Ministry of Public Health (Moph), agrees that migration has increased the burden on Thailand's health services and manpower, and added challenges to the disease surveillance and outbreak control system. He also acknowledges that the burden is one that can't be ignored.
Under his nine-year watch in Tak province,the public health system has initiated a number of programmes to target migrant populations and increase their access to medical services.
These included a migrant health worker and volunteer programme, as well as an ini-tiative targeting malaria."The security of the country is security in the health of the people living in it, no matter if they are Thai or not,"said Dr Supakit.
Indeed, these migrant populations, who tend to live in cramped and unsanitary conditions, are often those most vulnerable to disease outbreaks and severe medical problems. Yet because of their mobility, they are also the most difficult to treat.
Dr Supakit spoke of concerns over outbreaks of cholera and emerging diseases like meningococcal meningitis in the border areas.
Tuberculosis, a disease once thought to have been largely conquered in Thailand,now has a strong and increasingly threatening presence in the form of drug-resistant strains along the border. Handfuls of cases of multidrug resistant and extremely drug-resistant forms of the disease have been detected in recent years.
Tuberculosis is a special concern among migrant populations because of the intensive six-month regimen needed to treat the disease.
Health workers speak of challenges in getting migrant patients to complete treatment - often they will begin to feel better and stop coming while at other times, they simply disappear.
In one case a worker being treated was learned to have been arrested and placed in the Immigration Detention Centre. Because of bureaucratic obstacles, it took the NGO nearly two weeks to get him the drugs he needed.
Yet, while many public health workers and officers at Moph agree with Dr Supakit's sentiments, there remains a disconnect between ideology and financing.
"Moph allocates money according to provincial headcounts, which exclude migrant populations. Hospitals cannot request extra budgets, and the government cannot allocate it. You can't spend money you don't have,"Dr Patjuban said.
The reasons for the rising costs are not as clear-cut as they might seem. While there have long been migrants in the border province - in Mae Sot and surrounding districts the Burmese population is estimated at more than 400,000- there hasn't always been hospital debt.
In 2005 and 2006, Mae Sot General Hospital actually earned enough revenue through the Compulsory Migrant Health Insurance (CMHI)scheme to cover the medical costs of both registered and unregistered migrant patients,said Dr Ronnatrai Ruangweerayut, the hospital's deputy director.
He blames the shortfalls that have arisen since largely on the decreasing number of registered workers, a problem which is as much the making of policy makers as it is of Mae Sot's migrants.
According to statistics from the Ministry of Labour,85% of migrant workers living in Thailand in 2004 were registered and insured.Workers pay an annal fee of 1,900 baht for a health screening and insurance that entitles them to health care similar to that available to Thai citizens.
The registration rate has fallen precipitously ever since - only 30% of migrant workers were registered in 2007- because of the restrictive nature (it had been closed to new workers) of the registration programme. Dr Ronnatrai estimates that only 20% of Mae Sot's migrant population is now registered.This figure is bound to increase, as the government opened registration to new migrants earlier this year.
However, the Thai government's recent promise to permanently close the border suggests a likely continuation in the pattern of decline in terms of registration.
As the number of registered migrants has fallen, so too has revenue from CMHI. Hospitals now have a fraction of the income generated through the insurance programme to care for a growing, or at least equal, number of migrants. Revenue collected from CMHI fell from 800 million baht in 2005 to 500 million baht in 2006. At the same time, fewer migrants are entitled to care and more are likely to face out-of-pocket health expenses they cannot afford.
The amount of health services provided free of charge to Burmese rose from nearly 44 million baht in 2006 to 49 million baht in 2008.
Before the advent of universal healthcare coverage in Thailand in 2001, hospitals used the income generated from out-of-pocket payments to fund care for those who could not afford it. With that income no longer available, hospitals and provinces are on their own. Dr Ronnatrai said his hospital has already burned through its past savings and has appealed, along with the Moph, to the government to allocate an additional budget to provinces with large stateless and migrant populations. Their requests have been denied.PROVINCIAL DIFFERENCES While Tak struggles with swelling health care costs, many provinces - some also with large migrant populations - continue to generate significant income through CMHI. Samut Sakhon and Rayong provinces, hubs for migrants working in the Thai fishing and manufacturing sectors, both generated nearly 10 million baht in revenue in 2006 through the insurance scheme, even after covering the costs of services that uninsured and unregistered workers could not afford.
Dr Supakit says the discrepancies are due to the particularities of each province. Tak has far more unregistered workers than registered ones, while that gap is not as great in Samut Sakhon and Rayong. Uninsured workers in these provinces, where wages are higher,may also be more able to pay out-of-pocket medical costs than those in Tak.
Just as hospital exemption payments for unregistered migrants have increased over the years, so too have out-of-pocket health payments made by migrants. Nationally, hospital exemptions in 2006 cost 170 million baht, while out-of-pocket costs by unregistered migrants totaled 120 million baht. In addition,registered migrants contributed 493 million baht through the CMHI scheme. This data includes only 47 provinces.
Any surplus income earned through the system is used, at the discretion of individual hospitals or provinces, to subsidise the costs of providing care to unregistered migrants and stateless people. In most cases, this income exceeds the costs of exempted payments and theoretically is intended for outreach to migrants in the community.
Though this is the expectation, it's hard to know what becomes of this surplus funding. Reports of populations covered and revenue collected through the CMHI scheme have been incomplete and inadequate, despite the fact that the Moph requests all provinces to report their data to the central office.
In 2007, only nine provinces submitted data - four of these are sites of IOM-Moph migrant health projects - down from 65 in 2004 and 46 and 47 in 2005 and 2006, respectively.
"There is no real enforcement of the penalty for those that don't do it," said Dr Nigoon Jitthai, programme manager of International Organisation of Migration's (IOM) Thailand Health programme, which since 2003 has collaborated with the Moph on a Migrant Health Program.
Meanwhile, figures which have been reported vary widely and attract questions on their own.
"The governance and management of the funds is being questioned by everybody, as it seems that it lacks transparency. Many NGOs have tried to find out how the funds are managed and how exactly the funds are spent,without success. To be honest, no one knows how the surplus is used," said Dr Nigoon.
Dr Supakit agrees that reporting has been a problem, and has for several years been working to establish a Migrant Health Management Information System to better monitor migrant health financing and population data.
The surplus funds in many provinces suggest to Dr Nigoon that the public health services - even those in Mae Sot - to which registered workers are entitled through CMHI,are vastly underused. Data from the Moph show that from 2004-2006, registered migrant workers were half as likely to visit public health centres as other insured patients insured migrant workers averaged less than one visit per year, while Thais under the universal coverage plan seek services an average of 2.5 times per year.
Dr Nigoon says this under-utilisation is due to several factors, including fear of local authorities - even those that are registered tend to feel this way - a lack of awareness of their coverage, long working hours, long journeys to health care facilities, restrictive employers, and perhaps, as a consequence of all of these, the preference to self-medicate.
She says the self-medication is unfortunate as migrants may lose money for inappropriate treatment, health providers may miss health developments within migrant populations,and in cases of infectious diseases, the chronic misuse of antibiotics etc can cause drug resistance.
Available data continues to show that migrants under the CMHI scheme are most likely to seek treatment when health cases are quite severe and require in-patient care.
While Dr Supakit calls CMHI an effective system for those it covers, he acknowledges there are some locations where there may not be adequate translators or cultural help for migrant workers to feel comfortable in accessing it. Those who are not covered by CMHI - stateless persons and illegal migrants - present the complications.
Accordingly, he recommends that policy makers adopt a system that will facilitate migrant workers into insurance schemes."The more they are insured, the better health insurance can survive."
While this year's influx of one million migrants into the registration system should buoy, or further bloat, hospitals' CMHI accounts, the increase will not resolve the disparities and gaps within the funding system.
A handful of NGOs and international organisations like IOM continue to pitch in, in areas where service is most patchy. These efforts are often specifically targetted to provide TB services or HIV/Aids prevention, though others more broadly address the migrant community's health needs. IOM, for example,funds several community health posts and the training and service of migrant health workers.
A health worker in a post in Tak's Thasong Yang district - a young Karen woman whose family has lived in Thailand for more than 40 years, but lacks Thai citizenship - attends the health needs of her village's 884 members,sometimes around-the-clock as her home is next to the health post, providing basic care.
Much relief also comes from Mae Sot's Mae Tao Clinic, an internationally-funded operation that in 2006 had a caseload of 80,000 and expended 55 million baht in health services to Burmese patients. Half of these came from Burma for treatment.
While the Moph and provincial health offices have recently absorbed some programmes once supported by IOM, in a nod for sustainability, much of the external assistance comes with an expiration date, and provides neither a complete nor permanent fix.
Dr Patjuban grapples with how to keep the population of Tak healthy, and his public health services financially solvent."The shortages impact the whole system. We need more human resources, more equipment.It's an insufficient budget."
While Tak province receives assistance for funding migrant health care from a handful of NGOs, the inequalities of the migrant health care system and lack of assistance from the government get to him.
"For education, its not a problem. The resources are allocated," he says, referencing the Education for All programme that, at least theoretically, provides education to Thais and non-Thais."Why more funding for education, but none for health?" he asks.
He sees no light at the end of the tunnel,and having given up on on his own government turns to another."The strain on our system is great. We need Burma to improve."
When Mae Sot General Hospital first ran out of space a few years ago,hospital staff pitched tents and dragged out old beds. Since then, the problem hasn't improved - the crowded conditions have become more frequent and new beds have been permanently stationed in the hospital corridors. They are seldom empty.
But beds are hardly the extent of the hospital's resource problems. The hospital has a skeleton staff of five Burmese migrants serving as health workers and translators who assist Thai health personnel, but because of labour regulations they are technically employed as domestic workers. The Ministry of Labour limits migrant workers to low-skill work in the agricultural, manufacturing, fisheries or domestic sectors.
The waiting room is invariably crowded,and hospital personnel are overworked. Last year the hospital ran a 50 million baht deficit.
The reason for this debt is well known,and a subject on the minds of hospital administrators, public health officials, NGO staff and a number of Thai patients who ask their doctors why they must treat patients from Burma - the rising cost of providing health care to Mae Sot's migrant population.
Dr Patjuban Hemhongsa, chief medical officer for Tak province, home to Mae Sot and 30 formal points of entry on the ThaiBurma border, looked exasperated when asked about the issue. He called Tak "a perfect place for so many problems we can't solve refugees, stateless, displaced persons and a continuous flow of illegal migrants. There is no budget or system to care for them".
Dr Supakit Sirilak, director of the Bureau of Policy and Strategy for the Ministry of Public Health (Moph), agrees that migration has increased the burden on Thailand's health services and manpower, and added challenges to the disease surveillance and outbreak control system. He also acknowledges that the burden is one that can't be ignored.
Under his nine-year watch in Tak province,the public health system has initiated a number of programmes to target migrant populations and increase their access to medical services.
These included a migrant health worker and volunteer programme, as well as an ini-tiative targeting malaria."The security of the country is security in the health of the people living in it, no matter if they are Thai or not,"said Dr Supakit.
Indeed, these migrant populations, who tend to live in cramped and unsanitary conditions, are often those most vulnerable to disease outbreaks and severe medical problems. Yet because of their mobility, they are also the most difficult to treat.
Dr Supakit spoke of concerns over outbreaks of cholera and emerging diseases like meningococcal meningitis in the border areas.
Tuberculosis, a disease once thought to have been largely conquered in Thailand,now has a strong and increasingly threatening presence in the form of drug-resistant strains along the border. Handfuls of cases of multidrug resistant and extremely drug-resistant forms of the disease have been detected in recent years.
Tuberculosis is a special concern among migrant populations because of the intensive six-month regimen needed to treat the disease.
Health workers speak of challenges in getting migrant patients to complete treatment - often they will begin to feel better and stop coming while at other times, they simply disappear.
In one case a worker being treated was learned to have been arrested and placed in the Immigration Detention Centre. Because of bureaucratic obstacles, it took the NGO nearly two weeks to get him the drugs he needed.
Yet, while many public health workers and officers at Moph agree with Dr Supakit's sentiments, there remains a disconnect between ideology and financing.
"Moph allocates money according to provincial headcounts, which exclude migrant populations. Hospitals cannot request extra budgets, and the government cannot allocate it. You can't spend money you don't have,"Dr Patjuban said.
The reasons for the rising costs are not as clear-cut as they might seem. While there have long been migrants in the border province - in Mae Sot and surrounding districts the Burmese population is estimated at more than 400,000- there hasn't always been hospital debt.
In 2005 and 2006, Mae Sot General Hospital actually earned enough revenue through the Compulsory Migrant Health Insurance (CMHI)scheme to cover the medical costs of both registered and unregistered migrant patients,said Dr Ronnatrai Ruangweerayut, the hospital's deputy director.
He blames the shortfalls that have arisen since largely on the decreasing number of registered workers, a problem which is as much the making of policy makers as it is of Mae Sot's migrants.
According to statistics from the Ministry of Labour,85% of migrant workers living in Thailand in 2004 were registered and insured.Workers pay an annal fee of 1,900 baht for a health screening and insurance that entitles them to health care similar to that available to Thai citizens.
The registration rate has fallen precipitously ever since - only 30% of migrant workers were registered in 2007- because of the restrictive nature (it had been closed to new workers) of the registration programme. Dr Ronnatrai estimates that only 20% of Mae Sot's migrant population is now registered.This figure is bound to increase, as the government opened registration to new migrants earlier this year.
However, the Thai government's recent promise to permanently close the border suggests a likely continuation in the pattern of decline in terms of registration.
As the number of registered migrants has fallen, so too has revenue from CMHI. Hospitals now have a fraction of the income generated through the insurance programme to care for a growing, or at least equal, number of migrants. Revenue collected from CMHI fell from 800 million baht in 2005 to 500 million baht in 2006. At the same time, fewer migrants are entitled to care and more are likely to face out-of-pocket health expenses they cannot afford.
The amount of health services provided free of charge to Burmese rose from nearly 44 million baht in 2006 to 49 million baht in 2008.
Before the advent of universal healthcare coverage in Thailand in 2001, hospitals used the income generated from out-of-pocket payments to fund care for those who could not afford it. With that income no longer available, hospitals and provinces are on their own. Dr Ronnatrai said his hospital has already burned through its past savings and has appealed, along with the Moph, to the government to allocate an additional budget to provinces with large stateless and migrant populations. Their requests have been denied.PROVINCIAL DIFFERENCES While Tak struggles with swelling health care costs, many provinces - some also with large migrant populations - continue to generate significant income through CMHI. Samut Sakhon and Rayong provinces, hubs for migrants working in the Thai fishing and manufacturing sectors, both generated nearly 10 million baht in revenue in 2006 through the insurance scheme, even after covering the costs of services that uninsured and unregistered workers could not afford.
Dr Supakit says the discrepancies are due to the particularities of each province. Tak has far more unregistered workers than registered ones, while that gap is not as great in Samut Sakhon and Rayong. Uninsured workers in these provinces, where wages are higher,may also be more able to pay out-of-pocket medical costs than those in Tak.
Just as hospital exemption payments for unregistered migrants have increased over the years, so too have out-of-pocket health payments made by migrants. Nationally, hospital exemptions in 2006 cost 170 million baht, while out-of-pocket costs by unregistered migrants totaled 120 million baht. In addition,registered migrants contributed 493 million baht through the CMHI scheme. This data includes only 47 provinces.
Any surplus income earned through the system is used, at the discretion of individual hospitals or provinces, to subsidise the costs of providing care to unregistered migrants and stateless people. In most cases, this income exceeds the costs of exempted payments and theoretically is intended for outreach to migrants in the community.
Though this is the expectation, it's hard to know what becomes of this surplus funding. Reports of populations covered and revenue collected through the CMHI scheme have been incomplete and inadequate, despite the fact that the Moph requests all provinces to report their data to the central office.
In 2007, only nine provinces submitted data - four of these are sites of IOM-Moph migrant health projects - down from 65 in 2004 and 46 and 47 in 2005 and 2006, respectively.
"There is no real enforcement of the penalty for those that don't do it," said Dr Nigoon Jitthai, programme manager of International Organisation of Migration's (IOM) Thailand Health programme, which since 2003 has collaborated with the Moph on a Migrant Health Program.
Meanwhile, figures which have been reported vary widely and attract questions on their own.
"The governance and management of the funds is being questioned by everybody, as it seems that it lacks transparency. Many NGOs have tried to find out how the funds are managed and how exactly the funds are spent,without success. To be honest, no one knows how the surplus is used," said Dr Nigoon.
Dr Supakit agrees that reporting has been a problem, and has for several years been working to establish a Migrant Health Management Information System to better monitor migrant health financing and population data.
The surplus funds in many provinces suggest to Dr Nigoon that the public health services - even those in Mae Sot - to which registered workers are entitled through CMHI,are vastly underused. Data from the Moph show that from 2004-2006, registered migrant workers were half as likely to visit public health centres as other insured patients insured migrant workers averaged less than one visit per year, while Thais under the universal coverage plan seek services an average of 2.5 times per year.
Dr Nigoon says this under-utilisation is due to several factors, including fear of local authorities - even those that are registered tend to feel this way - a lack of awareness of their coverage, long working hours, long journeys to health care facilities, restrictive employers, and perhaps, as a consequence of all of these, the preference to self-medicate.
She says the self-medication is unfortunate as migrants may lose money for inappropriate treatment, health providers may miss health developments within migrant populations,and in cases of infectious diseases, the chronic misuse of antibiotics etc can cause drug resistance.
Available data continues to show that migrants under the CMHI scheme are most likely to seek treatment when health cases are quite severe and require in-patient care.
While Dr Supakit calls CMHI an effective system for those it covers, he acknowledges there are some locations where there may not be adequate translators or cultural help for migrant workers to feel comfortable in accessing it. Those who are not covered by CMHI - stateless persons and illegal migrants - present the complications.
Accordingly, he recommends that policy makers adopt a system that will facilitate migrant workers into insurance schemes."The more they are insured, the better health insurance can survive."
While this year's influx of one million migrants into the registration system should buoy, or further bloat, hospitals' CMHI accounts, the increase will not resolve the disparities and gaps within the funding system.
A handful of NGOs and international organisations like IOM continue to pitch in, in areas where service is most patchy. These efforts are often specifically targetted to provide TB services or HIV/Aids prevention, though others more broadly address the migrant community's health needs. IOM, for example,funds several community health posts and the training and service of migrant health workers.
A health worker in a post in Tak's Thasong Yang district - a young Karen woman whose family has lived in Thailand for more than 40 years, but lacks Thai citizenship - attends the health needs of her village's 884 members,sometimes around-the-clock as her home is next to the health post, providing basic care.
Much relief also comes from Mae Sot's Mae Tao Clinic, an internationally-funded operation that in 2006 had a caseload of 80,000 and expended 55 million baht in health services to Burmese patients. Half of these came from Burma for treatment.
While the Moph and provincial health offices have recently absorbed some programmes once supported by IOM, in a nod for sustainability, much of the external assistance comes with an expiration date, and provides neither a complete nor permanent fix.
Dr Patjuban grapples with how to keep the population of Tak healthy, and his public health services financially solvent."The shortages impact the whole system. We need more human resources, more equipment.It's an insufficient budget."
While Tak province receives assistance for funding migrant health care from a handful of NGOs, the inequalities of the migrant health care system and lack of assistance from the government get to him.
"For education, its not a problem. The resources are allocated," he says, referencing the Education for All programme that, at least theoretically, provides education to Thais and non-Thais."Why more funding for education, but none for health?" he asks.
He sees no light at the end of the tunnel,and having given up on on his own government turns to another."The strain on our system is great. We need Burma to improve."
MOSQUITO-BORNE AFRICAN VIRUS "A THREAT TO WEST"
The United States and Europe face a new health threat from a mosquito-borne disease far more unpleasant than the West Nile virus that swept into North America a decade ago,a US expert said on Friday.
Chikungunya virus has spread beyond Africa since 2005, causing outbreaks and scores of fatalities in India and the French island of Reunion. It also has been detected in Italy, where it has begun to spread locally, as well as France.
"We're very worried," Dr James Diaz of the Louisiana University Health Sciences Center told a meeting on airlines,airports and disease transmission.
"Unlike West Nile virus, where nine out of 10 people are going to be totally asymptomatic, or may have a mild headache or a stiff neck, if you get Chikungunya you're going to be sick," he said.
"The disease can be fatal. It's a serious disease," Dr Diaz added."There is no vaccine."
Chikungunya infection causes fever,headache, fatigue, nausea, vomiting,muscle pain, rash and joint pain. Symptoms can last a few weeks, though some suffers have reported incapacitating joint pain or arthritis lasting months.
The disease was first discovered in Tanzania in 1952. Its name means "that which bends up" in the Makonde language spoken in northern Mozambique and southeastern Tanzania.
The virus could spread globally now because it can be carried by the Asian tiger mosquito, which is found across the world.
Chikungunya virus has spread beyond Africa since 2005, causing outbreaks and scores of fatalities in India and the French island of Reunion. It also has been detected in Italy, where it has begun to spread locally, as well as France.
"We're very worried," Dr James Diaz of the Louisiana University Health Sciences Center told a meeting on airlines,airports and disease transmission.
"Unlike West Nile virus, where nine out of 10 people are going to be totally asymptomatic, or may have a mild headache or a stiff neck, if you get Chikungunya you're going to be sick," he said.
"The disease can be fatal. It's a serious disease," Dr Diaz added."There is no vaccine."
Chikungunya infection causes fever,headache, fatigue, nausea, vomiting,muscle pain, rash and joint pain. Symptoms can last a few weeks, though some suffers have reported incapacitating joint pain or arthritis lasting months.
The disease was first discovered in Tanzania in 1952. Its name means "that which bends up" in the Makonde language spoken in northern Mozambique and southeastern Tanzania.
The virus could spread globally now because it can be carried by the Asian tiger mosquito, which is found across the world.
FRESH WAVE OF SWINE FLU INFECTS THOUSANDS IN MEXICO
Mexico was hit with 1,341 new swine flu cases since Monday, bringing the total to 26,338 ahead of the usual autumn flu season, health officials said yesterday.
The Health Ministry said one more person died from the A(H1N1) virus between Monday and Thursday, bringing the death toll to 218 in the country where the virus first emerged in April before becoming a pandemic. In late August, Health Minister Jose Angel Cordova estimated nearly one million people could be infected by the virus during the winter, out of a total population of 100 million in Mexico.
The official global flu death toll has reached 3,486, up 281 from a week ago, according to the World Health Organisation (WHO), which has reported 296,471 known cases of infection. That number is seenas far below actual figures as some countries lack systematic analysis.
The UN agency said the Americas region still has the highest death toll, at 2,625. The Asia-Pacific region reported 620 official fatalities, while Europe recorded at least 140 deaths.
In the Middle East, 61 people succumbed to the virus while in Africa, 40 people have died from it.
The WHO on Friday warned that the production of swine flu vaccines will fall "substantially" short of the amount needed to protect the global population.
"Current supplies of pandemic vaccine are inadequate for a world population in which virtually everyone is susceptible to infection by a new and readily contagious virus," WHO director general Margaret Chan said.
Despite new evidence that only one dose of the vaccines currently being tested will be enough for most people, WHO spokesman Gregory Hartl said output next year will be "sub-stantially less" than the 4.9 billion doeses annual production forecast.
Some 25 pharmaceutical laboratories working on vaccines have indicated that weekly production is lower than 94 million doses, he said.
In May, the WHO had forecast a weekly output of 94.3 million doses if full scale vaccine production was launched.
But pharmaceutical companies have in recent weeks slashed their production expectations due to poorer than expected yields from the so-called "seed virus" strians developed by WHO-approved laboratories.
Amid growing fears that poorer nations will not get enough vaccines, the United States led nine countries which on Thursday pledged to make 10 per cent of their swine flu vaccine supply available to other nations in need.
The UN health agency's chief applauded the move the United States, Australia, Brazil, Britain, France, Italy, New Zealand, Norway and Switzerland.
Mexico Health Minister Jose Angel Cordova estimated nearly 1 million people could be infected.
The Health Ministry said one more person died from the A(H1N1) virus between Monday and Thursday, bringing the death toll to 218 in the country where the virus first emerged in April before becoming a pandemic. In late August, Health Minister Jose Angel Cordova estimated nearly one million people could be infected by the virus during the winter, out of a total population of 100 million in Mexico.
The official global flu death toll has reached 3,486, up 281 from a week ago, according to the World Health Organisation (WHO), which has reported 296,471 known cases of infection. That number is seenas far below actual figures as some countries lack systematic analysis.
The UN agency said the Americas region still has the highest death toll, at 2,625. The Asia-Pacific region reported 620 official fatalities, while Europe recorded at least 140 deaths.
In the Middle East, 61 people succumbed to the virus while in Africa, 40 people have died from it.
The WHO on Friday warned that the production of swine flu vaccines will fall "substantially" short of the amount needed to protect the global population.
"Current supplies of pandemic vaccine are inadequate for a world population in which virtually everyone is susceptible to infection by a new and readily contagious virus," WHO director general Margaret Chan said.
Despite new evidence that only one dose of the vaccines currently being tested will be enough for most people, WHO spokesman Gregory Hartl said output next year will be "sub-stantially less" than the 4.9 billion doeses annual production forecast.
Some 25 pharmaceutical laboratories working on vaccines have indicated that weekly production is lower than 94 million doses, he said.
In May, the WHO had forecast a weekly output of 94.3 million doses if full scale vaccine production was launched.
But pharmaceutical companies have in recent weeks slashed their production expectations due to poorer than expected yields from the so-called "seed virus" strians developed by WHO-approved laboratories.
Amid growing fears that poorer nations will not get enough vaccines, the United States led nine countries which on Thursday pledged to make 10 per cent of their swine flu vaccine supply available to other nations in need.
The UN health agency's chief applauded the move the United States, Australia, Brazil, Britain, France, Italy, New Zealand, Norway and Switzerland.
Mexico Health Minister Jose Angel Cordova estimated nearly 1 million people could be infected.
Human trials of flu jab delayed again
Human trials of the Thai-made type-A (H1N1) influenza vaccine have been delayed for the second time after the World Health Organisation recommended the Thai team conduct more studies on the trial jab's safety.
Vichai Chokewiwat, the Government Pharmaceutical Organisation (GPO)chairman, said the WHO viewed that Thai scientists were new to the production of live-attenuated vaccine, so the country should take careful steps in producing a vaccine.
The WHO's recommendation came after the Thai team detected an abscess in a rat injected with its trial H1N1 vaccine earlier this month.
Although the WHO experts concluded that the abscess had nothing to do with the trial vaccine, they recommended more studies be done before Thailand goes ahead with human trials.
"So we decided to postpone the vaccine testing on humans for 10 more days. The trials will begin on Oct 5," Dr Vichai said after the meeting of a committee on vaccine trials on humans which he chaired yesterday.
The human testing was originally scheduled for Sept 21, but was later postponed to Sept 24 and then Oct 5.
"Yes, we are worried that Thailand's H1N1 vaccine development project is not going as smoothly as expected, but we have come this far and we won't give up," said Dr Vichai.
In the meantime, the GPO would recruit volunteers for vaccine trials.
The GPO planned to conduct vaccine tests on 24 volunteers, but only seven were on the list as most of the applicants did not meet the testing requirements.
In another development, the subcommittee on immunisation practices,a body that counsels the government on vaccine matters, yesterday proposed a priority list of H1N1 vaccine recipients.
The advisory panel would next week submit the list to the Public Health Ministry for review and then help state and local health departments plan for a vaccination campaign as soon as the previously-ordered 2 million vaccines arrive around December and January.
Under the list, health care workers,pregnant women and those with obesity problems will be among people first in line to receive the vaccine, followed by those with chronic diseases and developmental disabilities, totalling 5 million,who are at the highest risk of complications from the new flu strain.
Somchai Chakrabhandu, Disease Control Department chief, said the recommendation is based on the number of fatalities reported by the Bureau of Epidemiology.
The type-A H1N1 flu has caused over 10,000 hospitalisations and 153 deaths in 56 provinces as of Sept 16. Most of them were among these risk groups,except for the healthcare workers.
Charung Muangchana, director of the national vaccine committee, said an estimated 400,000 healthcare workers are listed to receive the vaccine first because they are on the front lines in providing services at hospitals.
Vichai Chokewiwat, the Government Pharmaceutical Organisation (GPO)chairman, said the WHO viewed that Thai scientists were new to the production of live-attenuated vaccine, so the country should take careful steps in producing a vaccine.
The WHO's recommendation came after the Thai team detected an abscess in a rat injected with its trial H1N1 vaccine earlier this month.
Although the WHO experts concluded that the abscess had nothing to do with the trial vaccine, they recommended more studies be done before Thailand goes ahead with human trials.
"So we decided to postpone the vaccine testing on humans for 10 more days. The trials will begin on Oct 5," Dr Vichai said after the meeting of a committee on vaccine trials on humans which he chaired yesterday.
The human testing was originally scheduled for Sept 21, but was later postponed to Sept 24 and then Oct 5.
"Yes, we are worried that Thailand's H1N1 vaccine development project is not going as smoothly as expected, but we have come this far and we won't give up," said Dr Vichai.
In the meantime, the GPO would recruit volunteers for vaccine trials.
The GPO planned to conduct vaccine tests on 24 volunteers, but only seven were on the list as most of the applicants did not meet the testing requirements.
In another development, the subcommittee on immunisation practices,a body that counsels the government on vaccine matters, yesterday proposed a priority list of H1N1 vaccine recipients.
The advisory panel would next week submit the list to the Public Health Ministry for review and then help state and local health departments plan for a vaccination campaign as soon as the previously-ordered 2 million vaccines arrive around December and January.
Under the list, health care workers,pregnant women and those with obesity problems will be among people first in line to receive the vaccine, followed by those with chronic diseases and developmental disabilities, totalling 5 million,who are at the highest risk of complications from the new flu strain.
Somchai Chakrabhandu, Disease Control Department chief, said the recommendation is based on the number of fatalities reported by the Bureau of Epidemiology.
The type-A H1N1 flu has caused over 10,000 hospitalisations and 153 deaths in 56 provinces as of Sept 16. Most of them were among these risk groups,except for the healthcare workers.
Charung Muangchana, director of the national vaccine committee, said an estimated 400,000 healthcare workers are listed to receive the vaccine first because they are on the front lines in providing services at hospitals.
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