"Located on a strategic cross-roads in Asia, the borderlands of Burma (Myanmar)1 have witnessed extraordinary social and political upheaval during the past two decades. However, unlike in the adjoining states of China and Thailand, malaria morbidity and other health crises have remained at internationally high and often epidemic levels. It is a legacy that exemplifies much about the state failures of contemporary Burma. It is also a record of humanitarian malaise that, with too few exceptions, reflects the failure of key stakeholders in both Burma and the international community to prioritize health needs and conflict resolution in one of Asia’s poorest lands. Far too late, a notion of humanitarian crisis has developed that in 2006 witnessed briefings about Burma at the United Nations Security Council (UNSC) on the basis that, along with political impasse, the transmission of malaria, HIV and tuberculosis across international frontiers could pose a threat to regional peace and security.2 In reality, however, this is an analysis of humanitarian emergency that could have been made at any time in any of the preceding 20 years. In Burma, the humanitarian and political challenges have long been inextricably inter-linked. As the UNSC briefings highlight, any discussion about health issues in Burma is invariably tinged with controversy and, very often, doubt. There is a paucity of research in many health and socio-economic fields. But about the national significance of malaria, there can be no uncertainty. Data from every part of the country has long since pointed to the disease as Burma’s pre-eminent health challenge. Official statistics presently record malaria as the leading cause of both morbidity and mortality among the country’s ten priority diseases, with incidence rates of 11.1/1000 and 3.65/100,000 respectively.3 Plasmodium falciparum has been identified as the cause of around 80 per cent of the 600- 700,000 cases and 3,000 deaths reported annually.4 And a recent study estimated that Burma accounts for around 7 per cent of cases reported by the World Health Organisation (WHO) in the Southeast Asia region (including India), but 53.6 per cent of all malariarelated deaths.5 The difficulties, however, in addressing Burma’s malaria challenges go very much further. Malaria is acknowledged to be endemic in 284 of the country’s 324 townships, with over 70 per cent of the 54 million population at risk.6 But in vast areas of the countryside there is little access to basic health care, and it is estimated by the UN that only 25-40 per cent of malaria suspects currently seek treatment in the public sector.7 Indeed one UNICEF estimate in the early 1990s claimed that the real levels of malaria incidence could be up to seven times higher than WHO figures.8 Against this backdrop, multi-drug resistant malaria has become widespread, and essential combination drug treatments are frequently beyond the reach of the most at risk populations. As in all countries, the recorded incidence of malaria in Burma often reflects local pockets of emergency that can be attributed to particular environmental or socioeconomic factors. About 60 per cent of recorded cases, for example, are considered to be related to “forestry work”. 9 However mapping on a national scale reveals a much more disturbing reality, explaining why malaria has remained so endemic and with such high levels of morbidity.10 The areas of greatest risk exactly match the rugged horseshoe of highlands that surround the central Irrawaddy plains. In these areas, four characteristics stand out: they are borderlands adjoining the neighbouring states of Bangladesh, India, China, Laos and Thailand; they are heavily forested; they are inhabited by ethnic minority peoples; and they are the scenes of among the longest-running and most diverse insurgencies to be found anywhere in the world. The consequences of such frontier-land volatility have been profound, underpinning many of the health and political crises in the country. For decades, many different state and quasi-state actors have competed for authority in the borderlands. However during the era of Gen. Ne Win’s isolationist Burmese Way to Socialism (1962-88), public health care never extended to more than one third of the country.11 Meanwhile many of the borderlands remained under the de facto control of different armed opposition forces, including the Kachin Independence Organisation, Karen National Union, New Mon State Party and Shan State Progress Party. Each of these different authorities administered its own system of field clinics and health programmes. But whether in government or antigovernment areas, clinical diagnosis and appropriate treatment were frequently unavailable for most communities. Equally serious, there was no real coordination on public education nor on national and international responses to disease. Every kind of drug – both real and fake – entered Burma through blackmarkets that flourished along the frontiers with Thailand, China, India and Bangladesh. This proved especially damaging in the case of malaria. As research by the Shoklo Malaria Research Unit (SMRU) has demonstrated, conditions in Burma’s borderlands became very conducive to high levels of malaria infection and the spread of drug resistance.12 Throughout the Ne Win era, there remained little reliable data on humanitarian conditions in most regions of Burma. When media headlines occurred, it was only the lucrative trade in illicit opium and, from the mid-1980s, Karen refugees fleeing the fighting that alerted international attention to the endemic state of conflict in what had become one of the world’s most hermetic lands. Indeed so non-aligned had Burma become that in 1979 Ne Win even withdrew the country from the Non-Aligned Movement. But the seriousness of malaria incidence could never be disguised, and by 1988 the number of officially recorded malaria-related deaths had grown to over 4,000.13 It remained impossible, however, to put such statistics into any kind of national context. As any traveller in Burma’s borderlands could witness, malaria was the major cause of illness and death on far greater scale, evidenced by seasonal epidemics and the treatment of increasing numbers of refugees in neighbouring Thailand. A new landscape in both health needs and perspectives emerged following the 1988 collapse of Ne Win’s Burma Socialist Programme Party and the assumption of power by the present-day State Peace and Development Council ([SPDC] formerly State Law and Order Restoration Council [SLORC]). Three factors, especially, began to focus attention on the urgency and details of Burma’s health crises. The first was the accelerating departure of refugees and migrant workers into neighbouring countries. There can only be guesstimates about the exact scale of population movement since 1988 in what has become a constant state of cross-border human flow across some of the least regulated frontiers in Asia. But by the beginning of the 21st century, there were around 150,000 refugees (mainly ethnic Karen, Karenni and Mon) recorded in official camps in Thailand where there were also over one million migrant workers from Burma – both those described as “legal” and those “illegal”.14 In India, too, the refugee population is presently estimated as in excess of 50,000 (predominantly ethnic Chin), while during 1991-92 the Rakhine State border was the scene of one of the largest refugee exoduses in modern times when over 200,000 minority Muslims (known as Rohingyas) crossed into Bangladesh.15 In the following years, most of the Muslim refugee population was resettled back across the border under the auspices of the United Nations High Commissioner for Refugees. However the conditions of socio-political volatility along the Bangladesh and Burma’s other borders have generally continued. Such intervention by UN agencies leads to the second important change after 1988: the growing engagement by international aid organisations in and around Burma. The refugee populations along the Thai and Bangladesh borders have remained a principal focus of international concern. However from the early 1990s the new military government of the SLORC-SPDC also began allowing international aid agencies access to many off-limits parts of Burma. As the first international analysts conducted research in a quarter of a century, they swiftly began providing data confirming what health workers in the country had always known but could rarely address: the close links between conflict, public health failures and humanitarian suffering. In the early 1990s, the scale of its discoveries led UNICEF to frame the concept of Burma’s “Silent Emergency”, considering an appeal for “humanitarian ceasefires” to deliver relief aid to conflict-affected parts of the country.16 UNICEF’s strategies for “corridors of peace” through the borderlands remained on the drawing boards. But with the impetus of international analysis, public health statistics in Burma began to show more accuracy. In 1992 the official infant mortality rate was doubled to 94 per 1,000 live births, while there were estimates that the figure in conflict areas of the Karen and Shan States could be as high as 200 to 300 per 1,000 live births.17 As the new health data showed, children under five were accounting for nearly half the deaths annually recorded in Burma, due largely to a few treatable or preventable illnesses including malaria, pneumonia, measles and water-born diseases.18 Confirmatory evidence of the health complexities in the field then accelerated from the mid-1990s with the increasing access of non-governmental organisations (NGOs) into Burma. Their arrival coincided with the spread of ceasefires between the SLORC-SPDC government and a growing number of armed ethnic opposition groups. For the first time in three decades, day-to-day fighting halted in many conflict-torn areas, especially in the borderlands with China. In a break with past isolation, by the end of the 20th century around 20 international NGOs were registered inside Burma working on health issues.19 Their dynamic mirrored a resurgence in energy by local community-based organisations, 5 many of which also have an emphasis on health. Indeed, by one estimate, the 1990s saw the fastest decade in NGO growth in Burma’s history.20 It is important to stress that, throughout this period, the countrywide picture was by no means stable or even. In particular, there were several borderland areas where armed conflicts still continued. But whether due to humanitarian concerns inside or outside of Burma, this increased international focus on health issues meant that many of the particular causes and localities of health emergency became better identified. In the case of malaria, the borderlands with Bangladesh, India and Thailand became recognised as particular epicentres for high levels of malaria incidence. This led to increasing collaboration between international organisations and public health authorities in both Burma and abroad. New approaches were very clearly needed. A noteworthy example was Medecins Sans Frontieres-Netherlands (MSF-N) which, following its 1992 entry into Burma, prioritized malaria-related morbidity among vulnerable populations in the Rakhine State borderlands, treating over 100,000 malaria patients annually by the turn of the century.21 During the same years, the SMRU continued its anti-malarial programmes along the Thai border together with NGOs and the Thai government, helping reduce the incidence of P. falciparum by over 90 per cent in the refugee camps and surrounding regions.22 Recognition of these unaddressed “gateway” dynamics in the incidence of disease proved the final factor in changing perceptions about the nature of humanitarian crises in Burma. Neither conflict nor malaria, however, was the main catalyst for concern but HIV/AIDS which, during the 1990s, became a major health challenge throughout the sub-Asian region. With an international frontier-line of 3,650 miles, it was always likely that the patterns of human flow to and from Burma would be critical. Many worst fears were soon realised. From the first HIV sentinel surveillance begun in 1992, the number of officially estimated cases of HIV infection rapidly increased in Burma to around 350,000 adults in 2004-5, with a national prevalence rate of 1.3 per cent.23 As with malaria, however, there continue to be many doubts about statistics, with nongovernmental groups claiming national prevalence rates of 2 per cent or even higher.24 But on all sides of the arguments, there is recognition that many socio-economic conditions exist in Burma for the virulent spread of the disease, including borderland conflicts, intravenous drug users, commercial sex workers, mine workers and large numbers of other migrants.25 As UNAIDS points out, the spread of HIV infection in Burma is “heterogenous varying widely by geographical location and by population sub group”. 26 Equally concerning, there has been an inter-linked upsurge in the spread of tuberculosis during the past decade, with 97,000 new cases detected each year and a worrying increase in multi-drug resistance.