Think the Earth

Back to Table of Contents Mechanism

We often learn that technologies of Japanese companies we may have never heard of before are actually supporting super futuristic space development, or that a Japanese coach is directing a national team that may have suddenly made their mark. Without our knowing, there are people and mechanisms that bring on valuable change.
The stage for this Earth Report may be quite similar to this kind of situation.

Myanmar is a part of the Association of Southeast Asian Nations (ASEAN), sharing a border with China, India, Thailand, Laos, and Bangladesh. It is often associated with Japan's invasion during World War II, devout Buddhism, military government, and multi ethnicity, and is often referred to as the world's poorest nation. And for Japanese people who are a bit older, this country evokes a certain air of "nostalgia." It seems like this country has retained what Japan has lost during its development.

The streets of Yangon. The gold pagoda of the largest temple in Myanmar, Shwe Dagon, sparkles in the sunlight.
©HIROSHI ITO

Back to Table of Contents The ultimate goal is to help this country become independent
- The Japanese project manager of UNICEF

Myanmar, described as the world's poorest nation, is said to have a per capita GNP of 220 dollars, so approximately 20,000 yen. Nevertheless, due to political reasons, it is hard for the international aid from Western nations to reach the country. In Rwanda, for example, the per capita international aid is around 6,000 yen, while on the other hand Myanmar's is 300 yen.

Here in Myanmar, vaccinations for children, who are essential to the future development of the nation, are conducted in collaboration with the local government, UNICEF, and organizations that have donated funds. There are 3 key parties taking part in the polio NID that was conducted this year. There is UNICEF, which offers advice and training on the planning and operation using their know-how on supplying vaccines in developing countries; the Myanmar government and public administration that act as the main constituent of the project, secures the staffing, and runs the vaccinations in large cities as well as in small villages; and finally, there is the authorized NPO, Japan Committee "Vaccines for the World's Children" (JCV) which provides donations from, for example, individuals such as the baseball player who donates based on his own "rules" to supply the funds to purchase vaccines. NID is successfully conducted with the collaboration of these 3 parties.

Dr. Osamu Kunii from the UNICEF Myanmar office used to work in Somalia when he was younger. He used to treat many infected patients back then. But they would come back with a different illness, requiring more treatment, and this cycle went on and on, ending with the patient's eventual death. Many children and women died this way even though these diseases were all preventable. He remembers feeling extremely powerless. He became keenly aware of the importance of preventive medical care, and hence changed his career from a clinician to a specialist in public health. We asked him to give us an overview of the NID, a day on which polio vaccines are given to all children under the age of 5 in Myanmar.

Dr. Kunii from UNICEF Myanmar during the NID site inspection (center photograph). ©HIROSHI ITO

"Vaccination may be divided into 2 broad programs. Regular vaccinations (5 types - polio, paralysis, diphtheria-pertussis-tetanus (DPT), Bacille de Clamette et Guerin (BCG), and hepatitis B) are given each month to children under the age of 1. In addition to this, the NID gives vaccinations in high risk areas that are not covered by these regular vaccinations, or nationwide. Although polio had nearly disappeared for 6 years since 2000, there was an outbreak of vaccine-derived poliovirus*1 in 2006 and a wild strain of the poliovirus*2 in 2007. So in 2006 the vaccinations targeted specific regions, and in 2007 they were given nationwide once a year on NID. So, with approximately 7.4 million children around the country in mind, the project aims for a 95% vaccination rate."

*1　Vaccine-derived poliovirus: The given vaccine mutates, becoming toxic and turning into a virus.
*2　Wide poliovirus: Poliovirus that exist in the natural world.

The vaccinations required for polio, measles, and BCG are vulnerable to heat and light. And because depending on the type of the vaccination, they need to be either frozen or cooled (without being frozen), appropriate management facilities and personnel training are essential. If they are not stored under the proper conditions, there is a risk of giving children vaccinations that are ineffective. In order to make sure that the vaccinations work effectively, it is key to have a mechanism in place that lets you deliver vaccines under the right cold conditions without any hiccups. This system is referred to as the cold chain.

What does the cold chain in Myanmar look like?
First, donations from supporters in Japan are amassed by the JCV. After receiving requests based on the vaccination plans drafted by the local WHO and UNICEF offices as well as the Myanmar government, JCV decides on the amount of assistance to provide. Then it sends the necessary funds to UNICEF. Using the assistance, the UNICEF Supply Division in Copenhagen, Denmark starts to source vaccines. Vaccine companies all over the world take part in the bid each time, so the Supply Division is able to purchase quality assured vaccines for the lowest price possible. The system also assures on-time delivery of vaccines to the designated location. The conditions vary slightly depending on the type of vaccine and the time and location, but these vaccines sourced from factories all over the world are flown to Myanmar.

"The vaccines that arrive from different parts of the world first go to a central cold room in Yangon. This facility was built using funds from UNICEF and Japan International Cooperation Agency (JICA). Then the vaccines are delivered to central hospitals in 325 townships via 19 storage facilities around the country. But beyond these points, there are no power generation facilities that can supply electricity to refrigerators and freezers. The Rural Health Clinics (RHC) and the Sub-Health Centers (SHC), which are in even more remote areas and do not have sufficient facilities, so figuring out how to keep the vaccines at an adequate temperature is a very big issue. There are even some midwives who pay for ice out of their own pockets to keep the vaccines cold."

According to Dr. Kunii, although there are still issues that need to be resolved, the vaccination program in Myanmar is progressing steadily.

"In the beginning, we had to provide technical and financial support for the preparation, planning, through to implementation and evaluation of the program. But now everyone - from people in central to rural areas and even people working on the ground - recognizes the importance of the NIDs, and they have acquired the necessary skills to conduct them on their own. Nevertheless, our ultimate objective is not just conducting NIDs for polio; we would like to empower the Myanmar government, both technologically and financially, to conduct all vaccinations on their own. The final goal for providing assistance to a nation, is to help them become independent, so that they will no longer require aid."

After the NID this year, a smaller scale, sub-NID will be conducted in key areas around the nation that will give vaccinations to everyone in the region all at once. And if we can achieve an immunization rate of 95%, Myanmar will be able to declare that it is polio-free in the near future. UNICEF has already drawn up such plans.

(Left) If you are infected by the polio virus and become pathogenic, you will be affected by very serious residual effects such as numbness in the hands and feet. A photograph of promotional posters placed in various areas. ©HIROSHI ITO
(Right) Dr. Kyaw Myint Aung, a young, excellent doctor who is a member of the staff from UNICEF Myanmar works on the project with Dr. Kunii. He says, " I want to help as many people in my country as possible." ©HIROSHI ITO

Back to Table of Contents Roles

We took a closer look at the people who work on this program, by actually following the path of the cold chain that safely delivers vaccines to people all over Myanmar.

Back to Table of Contents Managing vaccines across Myanmar
- Staff working in the Ministry of Health

The vaccines sent to Myanmar from different parts of the world are delivered to the central cold room in Yangon. Dr. Kyaw Kan Kaung from the Ministry of Health is in charge of the management of the facility.

The central cold room in Yangon.

Dr. Kyaw Kan Kaung , from the Ministry of Health in charge of the management of the central cold room (right) and his boss, Dr. Than Thein Win.

"Because the old cold room had become decrepit, and it didn't have the sufficient capacity, we renovated an old warehouse and built a new one 2 years ago. It started operation last year, after the cyclone hit. It has 7 "walk-in cold rooms" big enough for people to freely walk around in. There are enough vaccines for 400,000 people stored in these rooms at all times, and depending on the type of vaccine, they are stored at specific temperatures in refrigerators and freezers" says Dr. Kyaw Kan Kaung.

The modern and hygienic cold room is located only 10 minutes from central Yangon, but it seems that there are still some unresolved issues.

"Because the power supply in Myanmar tends to be still unstable, power failures aren't quite frequent. That is why temperatures are maintained 24-7 using an independent power generation system. The vaccines are delivered to places across the nation from this cold room, but you can hardly say that there are sufficient transportation vehicles. But as we are in charge of vaccines for the entire nation, 10 members of the staff work in tandem to stringently manage the temperatures, so that the vaccines don't go to waste."

(Left) Walk-in cold room. (Right) In Japan, BCGs are given through a 9-needle injection. This vaccine prevents tuberculosis. ©HIROSHI ITO

(Upper left) This bottle contains enough polio vaccines for 20 people.
(Upper right) Ice bags and refrigerants used for transportation are also stored here. ©TAKASHI MORIOKA
(Lower left) Power generator used during the cyclone.
(Lower right) The vaccines are placed into these boxes, and delivered to areas across the country by air and land.

For them, the mission is very clear.
When we asked Dr. Than Thein Win, the supervising manager of the vaccination program from the Ministry of Health, about the goal for Myanmar, he replied clearly, without hesitation.

"Our 3 big goals are: eradicating polio, decreasing cases of pneumonia, and preventing measles. That is why we study up on new information about vaccines and implement new methods. Negotiating and developing relationships with JCV is also an important part of our job."

The vaccines are delivered by land and air to RHCs in 21 areas around the country, and then on to 325 townships following the path of a well planned cold chain.

A lime tree (tree of Buddha) found within the premises of the facility.

Back to Table of Contents Overcoming the cyclone and keeping an eye on NID
- A feminine force in regional medical treatment

Myanmar has a population of approximately 50 million people, has a total land area measuring 1.8 times the size of Japan, and is comprised of 325 townships. And doctors who are in charge of the general hospitals in each township and of the regional medical treatment are referred to as TMOs or Township Medical Officers.

We learned about a township called Bogale in the Ayeyarwaddy Division, which was severely affected by the cyclone that hit Myanmar in May 2008. The TMO here is Dr. Hle Hle Kgi. She has been involved in NIDs each year since 1997. She was placed in charge of the region right before the cyclone hit.

Dr. Hle Hle Kgi, the TMO of the Bogale township (right). "I inspected 3 areas traveling by boat yesterday." She went with a nurse, her right hand woman.

"There are 320,000 people living in this city. The cyclone took 34,000 lives. 31,000 children under 5 will be receiving polio vaccinations this time around. This amounts to approximately 1% of the population. The NID takes place over 2 days, but on the first day, which was yesterday, we vaccinated 99% of these children at 531 locations region wide. Today, we will vaccinate children who live in remote areas, who can't make it to the vaccination centers. With our list in hand, we visit every single home to vaccinate these children."

The Ayeyarwaddy Division refers to the area around the Ayeyarwaddy River, which is a delta area where tributaries big and small crisscross through like veins. The major means of transportation here are boats. Having said that, there are high waves in the southern areas near the sea, and there are places you can't get to within a day. So it's difficult to get to each and every settlement. Many people are astonished when they see a female TMO who come on a boat with her nursing staff through such conditions.

Boats are necessary to get around. During the rainy season, the water level rises, and the landscape changes drastically.

The cyclone completely or partially destroyed 70~80% of buildings in the region, and the cold chain was also severely affected (i.e. the vaccines became immersed in water). At one time, they could not even conduct regular vaccinations, but they managed to start back up again 2 months after the disaster. This was made possible with the fine assistance they received from UNICEF right after the disaster, but also with the rich experience and the great awareness of the TMO.

"This hospital has a solar power generation facility, so the temperature management of vaccines is in top shape here. There are also many fishermen in the area, so it's not hard to get ice making it relatively easy to deliver vaccines to villages and settlements. We are beginning to see that there are less and less people who are becoming infected with polio or the measles, so we feel that the parents are really beginning to recognize the importance of vaccinations."

(Upper left) Solar power generation system installed with the aid from UNICEF. It cost 600,000 yen to build.
(Upper right) The refrigerator in the hospital. Vaccines are delivered from here to the various vaccination centers. ©HIROSHI ITO
(Lower left) The vaccines are placed in individual vinyl bags to make sure that the labels don't come off while they are being cooled. © TAKASHI MORIOKA
(Lower right) At the vaccination centers in the region, the vaccines were kept cool with ice inside the transportation box.

The conditions in the 325 townships differ depending on their location and the region. In the northern area near the border, a limited number of staff must cover a wide region marked by steep Himalayan mountain ranges. And in another region, there are many ethnic minorities that speak different languages, so it is difficult to communicate the benefits of having vaccinations. But here in Bogale, Dr. Hle Hle Kgi over came the devastating affects of the cyclone, and pulled off the NID with great success. Her experience and confidence is sure to help other regions in the future.

Back to Table of Contents NID's Last Mile
- Midwives that provide medical care to the people in the region with the help of volunteers

Beyond the townships are the NID vaccination centers where the children are waiting. RHCs and SHCs are where the NIDs take place. We are nearing the end of the cold chain. This is what is often referred to as the "Last Mile."

We went and paid a visit to the Shan Kwin Gyi village, which is situated by the river in the Pyapon township in the Ayeyarwaddy delta. Like in many RHCs and SHCs, midwives play a key role here. Today is the first day of the NID. There are many mothers with their children under 5 from all over the village gathered in front of the SHC.

People gathered at the vaccination center. © TAKASHI MORIOKA

We asked the midwife, Ms. Than Than May, who is in charge of this SHC about what it was like to run the NID here.

Ms. Than Than May, who responds to the questions of the observers. © TAKASHI MORIOKA

"There are 307 families living in this village. That is 1,470 people, 187 children under 5, and 42 children under 1. I went to the RHC in Kyun Tar first thing in the morning to pick up vaccines that arrived yesterday from the central hospital in Pyapon. It's a 30-minute walk from here. There is also ice in the case we carry vaccines in, so we can keep it stable for 24 to 48 hours during the NID."

Boats are essential to get around this region. Ms. Than Than May also uses a boat or a motorcycle that her husband drives when paying other areas a visit

"We first check the names and ages of the children and mothers against the list. We are giving them polio vaccines and vitamin A at the same time, but we give them different tags, so that we can recognize their ages. Then we give them polio vaccines; 2 drops each. Then vitamin A. After they receive their vitamin A, we have them wait outside for about 15 minutes. We use a black marker to mark the fingernails of each child who has received the vaccine, so we can keep track."

(Left) There are children who are accompanied by their fathers. ©HIROSHI ITO
(Upper right) Polio vaccines taste sweet. Although it doesn't hurt, he has started to cry. ©HIROSHI ITO
(Middle right) Marking the fingernails of children who have received vaccinations. ©HIROSHI ITO
(Lower right) Dozens of local volunteers help out. ©TAKASHI MORIOKA

The limited space in the center is partitioned off into the reception area, polio vaccination corner, and the vitamin A corner. The children visit each corner in order. Although there are many people here, there doesn't seem to be any confusion. Usually the midwife single handedly manages this clinic, but during NIDs, she's gets great backup. Women wearing matching uniforms from a mother/child group and men who are fire fighters volunteer their services.

The NID is held with the help of all villagers not just in this village, but in every village. What was impressive about the "Last Mile" of the vaccine aid was the smiling faces of the children and their mothers and fathers, the many volunteers that help the midwives run the center, villagers that watch over the children protectively, and the people who gathered around the center.

Many villagers gathered around the center.
©TAKASHI MORIOKA

Young boys and girls that watch the vaccinations taking place. ©HIROSHI ITO

Back to Table of Contents * "I want to keep going until I retire"
- An interview with a midwife

The midwives who are in charge of the "Last Mile" of the NID are very busy. In addition to the roles the midwives in Japan play, they also serve as nurses, health advisors, and even doctors at times. Although their compensation may not be that great, they still work extremely hard. What drives them so? To get a better idea, we drove an hour from Yangon to the RHC in the village of Zaw Ti located in the Twante township on the day before the NID, to talk to the midwife who manages the center there.

(Left) It's been 15 years since she became a midwife.
(Right) The RHC she is in charge of. Although the building was completely destroyed by the cyclone, it was rebuilt with the help of an NGO in Italy. The volunteer staff that help her out.

What does your regular day at work look like?
"In the morning I run the clinic here and treat people for colds and other illnesses. In the afternoon I visit people's homes and treat them there. It's been 15 years since I began. I sleep here at the clinic during the week, and then go home over the weekend."

Do you like your work? What do you find especially difficult?
"I love my work. I am actually from a village nearby, located 30 minutes away from here. But people here treat me as if I were one of their own. Because this village doesn't have a doctor, giving birth is often difficult, but I feel very happy every time a baby is born without major complications."

What would you like to do in the future?
"Everyone in this villages is very calm and quiet, and nice. So I want to stay here and help them until I reach 60, my retirement age."

Her simple yet well-balanced response, as well as the way in which she calmly went about her work, despite having to take on so much was very impressive.

Back to Table of Contents Passion

The right system, and the people who steadfastly undertake their tasks exist in Myanmar. But what is essential to keeping this functioning sustainably is people's passion.

Back to Table of Contents How donations from "My Rules" reach the people who need them
- NPO staff

How do people from the NPO who stand between and talk to people from both Japan and Myanmar feel? We asked Ms. Reiko Ezaki, the Deputy Director-General of the authorized NPO, Japan Committee "Vaccines for the World's Children" who provided 80% of the vaccines given during the NID this year what she values the most.

Ms. Reiko Ezaki who came to the vaccination center located in a region affected by the cyclone. (The fourth person from the left)

"Since we have been working in Myanmar for over 10 years now, the name JCV has become well recognized by people in the medical industry in Myanmar. But we try to communicate that it is not the JCV that is donating the vaccines, rather it is people from all over Japan, from children to the elderly, who have donated them."

The funds gathered in Japan provide vaccines essential to the healthy growth of children in villages across Myanmar. There is a system there that has been built on the findings of the international society, and people who perform very clear roles. And it also seemed like the regional cooperative framework was in place and functioning. Nevertheless, not everyone who has donated can go to Myanmar to see what positive benefit their donations have had for themselves. So how can this be communicated to them?

"Of course providing data, such as quantitative information about aid is important, but what is most important is the reality. Numerous volunteers from JCV have gone to Myanmar to observe vaccinations taking place. There are many people who say that this experience made them think about their careers. By talking about it and sharing their experiences in various situations, i.e. in conversations and on blogs, people can communicate what the situation is really like in Myanmar. I think that it is important to widen our reach this way."

Here is a cooperative framework that transcends borders, a system that is operated on a national level, and people who unwaveringly fulfill their tasks.
People's sense of responsibility towards their work, their pride, sense of mission to contribute to the brighter future of their country, and the respect and trust placed in the people who fulfill these tasks - it may sound a bit too dramatic, but I felt as though I witnessed these things during my trip.

People wave to the observers leaving the clinic with great wide smiles.
©TAKASHI MORIOKA

When we spend money, we are also changing the world.