ZEE PHYU KWIN, Myanmar - In her long scarlet sarong, crisp white shirt and nurse's cap pinned neatly in place, Khin Aye Nwe looks as though she belongs in a modern hospital. Instead, the midwife's clean sandals scuff across the dusty cement floor of a dilapidated clinic in Myanmar's Irrawaddy Delta.
She covers a territory spanning 15 villages with 3,000 people, delivering babies, immunizing children and treating everything from malnutrition to malaria in an area where 80 per cent of young children and pregnant women are anemic.
For half a century, such work was almost completely ignored by the secretive military-run government, which starved virtually every sector of the budget except defence. Now, with the dramatic change that has given Myanmar an elected government, there are hopes for improvement, but the country faces a long climb. Under military rule, it spent less than $1 per person on health in 2008, minus donor money, and ranks among the lowest countries in nearly every category of health care funding.
Despite the neglect, Nwe and a small army of other dedicated women have continued to fan out across the country's vast rice basket to help the sick. They walk, ride buses, climb inside rickety boats and hop on the backs of motorbikes to reach patients who have no other source of medical care.
The work is exhausting, and Nwe knows no matter how hard she pushes herself, it will never be enough to help everyone. But she says now, for the first time, there's reason to hope.
"I'm not seeing it here yet," she says, softly. "I haven't seen the improvements or changes yet, but I think it will come."
The excitement following a wave of political reforms and historic international visits is easily felt in bigger cities such as Yangon, formerly named Rangoon, where T-shirts adorned with pro-democracy icon Aung San Suu Kyi's face are hawked at roadside stalls and Western business people are filling up hotel rooms.
But a half day's drive away into the delta, it's harder to sense that energy among the poor who live meal-to-meal in flimsy thatch huts on bamboo stilts along coffee-brown rivers and rice paddies.
After being isolated from the rest of the world for so long, many are used to expecting very little in a country where running water and electricity are still considered luxuries in many areas.
For years, the U.S. and others used economic sanctions to pressure the junta to clean up its dismal human rights record and allow democratic reforms. As international donor aid poured into nearby countries, with Cambodia, Vietnam and Laos receiving $52, $34 and $67 per capita respectively in 2010, Myanmar got $7.
That, combined with the junta's disregard, meant most people in Myanmar, also known as Burma, had to pay for what little health care they received, or do without.
Wracked by corruption and mismanagement, the country's overall health care system was ranked second worst in the world by the World Health Organization in 2000. The government spent the least of any country worldwide on health in 2009, as a percentage of the country's gross domestic product.
Its people pay the price in many ways:
— Myanmar has Southeast Asia's highest death rates for newborns, infants and children under 5.
— AIDS kills an estimated 18,000 people a year, and the country remains one of the hardest in which to receive HIV treatment.
— Tuberculosis is at nearly triple the global rate, and Myanmar has the highest number of malaria-related deaths in the region.
— More than 90 per cent of pregnant women and 70 per cent of children in coastal and delta areas suffer worm infestations, a major cause of malnutrition.
And all this is happening in a resource-rich country that was once the envy of its neighbours.
"Decades of disinvestment in health by Burma's rulers, coupled with the collapse of the education system and censorship, have left the country's public health system in ruins, without sufficient trained personnel or supplies to adequately offer basic, affordable health services for most Burmese," said Dr. Vit Suwanvanichkij of Johns Hopkins University.
The lack of care is obvious at the country's main hospital, Rangoon General in Yangon. Its once stately British colonial red-brick facade sprawls across a huge campus, but the grounds are cluttered with filth and weeds and food vendors sell cheap snacks to patients' relatives near open sewage gutters.
Inside one ward, dozens of patients are packed into an open room. Some drift in and out of sleep while others twist in obvious pain as family members fan them.
As the country continues opening its doors to the outside world, historic visits such last month's by President Barack Obama are symbolizing a new era.
A parade of high-ranking global health officials also have recently filed through the country, taking stock of what's left of the health system and vowing to help rebuild it. UNAIDS last month named Suu Kyi a global advocate to raise awareness of stigma and discrimination against HIV patients, a daunting problem in the country.
Myanmar has taken a few encouraging steps. Its new health minister, Dr. Pe Thet Khin, is a pediatrician with firsthand knowledge of the challenges.
In the U.S. earlier this year, he said he hoped new partnerships and collaborations with foreign universities would improve the quality of the country's health system. He added that infant, child and maternal health was considered a top priority.
He said the country is producing enough doctors, nurses and other health workers but that the quality was "a bit compromised" due to a lack of funding. "The economy, as you know, was not very good over the past 20 or 30 years, partly because of sanctions but partly because of some mismanagement," he said.
The new government has quadrupled the health budget, but it is still low and much of the budget increase went to paying health workers' salaries. National studies are also needed to provide a clearer picture of the true state of health, especially from restive areas where ethnic minorities have been at civil war for decades and travel was previously forbidden.
"The system here is so far behind," said Eamonn Murphy, UNAIDS country co-ordinator.
Myanmar once had a strong health and education system and could recover, he said, "but it's just going to take time and it's going to take a serious commitment from the international community, not just financial but technical."
Off the rocky, rutted dirt track in a faraway corner of the Delta where midwife Nwe works, UNICEF — not the government — has been running a program that provides vitamin- and mineral-packed sachets called Sprinkles to 3,000 children under age 3. The micronutrients are added to food to help ward off anemia caused by a lack of iron in an area of the country routinely hit by flooding and disasters — Cyclone Nargis killed more than 100,000 people in 2008.
Nwe quickly rattles off a wish list of improvements she'd like to see: more health workers and supplies, better infrastructure and transportation for staff and patients.
But she's also quick to note that the government has doubled staffing at the local health centre to deal with the heavy patient load. Doubled, that is, from one to two.
It's a very small thing, she knows, but it's enough to make her hope for more. And that's something she never would have dared in the past.
Follow Margie Mason on Twitter: twitter.com/MargieMasonAP