FATAL SILENCE?
Freedom of Expression and
the Right to Health in
ARTICLE 19
July 1996
ACKNOWLEDGEMENTS
This report was written by Martin Smith, a journalist and specialist
writer on
ARTICLE 19 gratefully acknowledges the support of the Open Society Institute for this publication.
ARTICLE 19 would also like to acknowledge the considerable
information, advice and constructive criticism supplied by very many different
individuals and organisations working in the health and humanitarian fields on
©ARTICLE 19
ISBN 1
870798139
All rights reserved. No part of this
publication may be photocopied, recorded or otherwise
reproduced, stored in a retrieval system or transmitted in any form by any electronic or technical means without prior permission of the copyright
owner and publisher.
Note by the editor of this Internet version
This version is a conversion to html of a
Word document - in the Library at http://www.ibiblio.org/obl/docs/FATAL-SILENCE.doc
- derived from a scan of the 1996 hard
copy. The footnotes, which in the original were numbered from 1 to __ at the
end of each chapter, are now placed at the end of the document, and number
1-207. The footnote references to earlier footnotes have been changed
accordingly. In addition, where online
versions exist of the documents referred to in the notes and bibliography, the
web addresses are given, which was not the case in the original. Otherwise, the
text follows the original.
CONTENTS
Abbreviations
Chapter
1 Overview
Chapter 2 Health Rights and Human
Rights: The Experience of
Chapter 3 The Health System in
Chapter 4 Health in a Society Under Censorship
Chapter 5 Political Restrictions on Medical
Practitioners
Chapter 6 Conflict and Humanitarian Crisis
6.1 The
Backdrop of War
6.2 Refugees and the
Internal Displacement of Civilians
6.3 The Health of Prisoners and Detainees
Chapter 7 AIDS and Narcotics
Chapter 8 Women and Health
Chapter 9
The International Perspective
Chapter 10 Conclusions and Recommendations
Selected Bibliography
“The enjoyment of the highest
attainable standard of health
is
one of the fundamental rights
of
every human being without
distinction of race, religion
or social
conditions”
World Health Organization Constitution
(Preamble)
ABBREVIATIONS
ABSDF All
AIDS acquired
immune deficiency syndrome
ASEAN Association
of South East Asian Nations
BADP Border
Areas Development Programme
BBC British Broadcasting
Corporation/Burmese Border Consortium
BPI
BSPP
CIA Central Intelligence Agency
DKBO Democratic
Karen Buddhist Organization
HIV human immunodeficiency virus
ICCPR International
Covenant on Civil and Political Rights
ICRC International
Committee of the Red Cross
IDU intravenous drug user
ILO International Labour Organization
IMR infant mortality rate
KIO Kachin
KNU Karen
National
KNPP Karenni National Progressive Party
MMA
MMCWA
MNRC Mon National Relief Committee
MP Member of Parliament
MRC
MSF Medecins Sans Frontieres
MTA Mong Tai Army
NGO non-governmental organization
NLD National
League for Democracy
SLORC State Law and Order Restoration Council
STD sexually-transmitted disease
UDHR Universal Declaration of Human Rights
UN United Nations
UNDP United Nations Development Programme
UNDCP United Nations International Drug Control
Programme
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children's Fund
UNPFA United Nations Population Fund
US United States of
USAID United States Agency for International Development
USDA Union Solidarity and Development Association
UWSP United Wa State
Party
WHO World Health Organization
Chapter 1
OVERVIEW
Censorship has long concealed a multitude of grave issues in
There are many elements involved in
addressing the health crisis which now besets
Although not comparable to the crises in
Health statistics can be notoriously
unreliable in
—
maternal mortality in
—
only one third of the country has access to
clean water or proper
sanitation;
—
nearly half of all children of primary school
age are
malnourished;
—
with only one doctor for every 12,500
people, the national
system of health care does not extend to even half the
country;
—
health education is woefully inadequate, and
only 25 per cent of
all children complete the five basic years of primary
school;
—
which has a grave health impact in both
international community at large;
—
HIV/AIDS is increasing at an alarming rate,
with estimates of
HIV-carriers increasing from near zero to 500,000 over
the past
six years;
—
displaced people as a result of civil war;
—
compulsorily resettled by the government, whose health
and
living conditions are also often poor;
—
finally, it is treatable or preventable
illnesses or conditions linked
to poor socio-economic status, such as intestinal
infestations,
pneumonia, tuberculosis, malnutrition, malaria and
complications arising from illicit abortions, which
continue to
be the main causes of unnecessary death and
ill-suffering in the
country.
Not surprisingly, in view of the scale of
these problems, virtually all international agencies
attempting to establish operations inside
For a long time the state of
While there can be little argument over
humanitarian need, many medical practitioners in Burma nevertheless
remain cautious about allowing the issue of health to be used as another
battleground by different actors and institutions during the
present political impasse. Under the military
State Law and Order Restoration Council (SLORC), which assumed power in 1988,
In such a polarized atmosphere, the universal
importance of human rights — including the right to health —
frequently becomes lost amidst arguments over political or security
priorities. Opposition groups, especially, have expressed grave
doubts over the effectiveness and equity of new health
programmes introduced by the SLORC. Without the rights
and institutions inherent in a democratic society, they argue, any health
impact will be necessarily limited and only related to projects that the
military government approves. Moreover, such health
projects will not address the many human rights violations, such as forced labour, forced relocations or summary arrests and imprisonment,
which themselves have an extremely detrimental impact on the health of individuals. According to Dr Thaung Htun, health spokesperson for the National Coalition Government Union of Burma, which consists of eleven exiled MPs who won seats in the 1990 election:
The humanitarian crisis in
By contrast, many other doctors and
community leaders hope that health and
development programmes will help create the social and political bonds necessary for rebuilding their long-divided societies after so
many years of suffering and conflict. This view is most prevalent in ethnic minority regions of the country where cease-fires have recently
been achieved by the SLORC with over a dozen armed ethnic opposition groups. According to this argument, the spirit of peace and social
regeneration in the war zones will eventually break the
political deadlock in
Despite such conciliatory words, however, the
tasks of social and political reconstruction now facing
This report, therefore, highlights crucial issues of health and human rights in a society under censorship, at a time of historic transition. Since few studies have ever been published on the national
health system in
In ARTICLE 19's view, these most fundamental
of human rights are absolutely central to the provision and enjoyment of
essential health care — which is itself a universal human right
— in any country in the world..
Chapter 2
HEALTH RIGHTS AND HUMAN RIGHTS
The Experience of
Everyone has the right to a standard of
living adequate for the health and well-being of
himself and his family, including food, clothing, housing
and medical care and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
In
addition, other provisions of the UDHR have a bearing on health. Article 3 guarantees "the right to life, liberty and security of
person", while Article 5 provides that "no one
shall be subjected to torture, or to cruel, inhuman or degrading treatment or
punishment".[7]
Based upon such fundamental tenets of human rights, over the years a
number of other human rights instruments have been adopted by governments which explicitly recognize a universal right to health. Some agreements relate to specific human rights violations, such as the 1987 Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Other health guarantees are contained in treaties that are intended to protect disadvantaged or particular social groups. For example, the right to health is invoked in Article 5 of the 1969 Convention on the Elimination of All Forms of Racial Discrimination, Articles 11 and 12 of the 1981 Convention on the Elimination of All Forms of Discrimination Against Women, and Article 24 of the 1989 Convention on the
Rights of the Child.
In practice, however, for doctors and other
health practitioners working in the field, recent research has suggested that medical
and ethical concerns over health and human
rights violations generally fall into
two main categories.[8] The first is the grievous impact that many human rights
violations have on health, including such gross violations as torture,
extrajudicial execution, rape, forcible resettlement or forced labour.[9] Whether administering to victims or addressing the humanitarian impact of war, health practitioners
are frequently principal witnesses
to the suffering and are thrust into the front line of care.
The second key area of concern is equally
critical: the impact that government policies and public health programmes or practices
themselves have on health and other human
rights. In this approach, it is recognized that the fundamental issue of health
care cannot be isolated from human rights more generally or from overall
social conditions. The broad social basis of the right to health was
most clearly stated in the historic Alma-Ata
Declaration of the World Health Organization
(WHO) and UNICEF, which was adopted at the International Conference on
Primary Health Care in 1978:
The Conference strongly reaffirms that health,
which
is a state of complete physical, mental and social
well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible
level of health is a most important
world-wide social goal whose
realisation requires the action of many other social and economic sectors in addition to the health sector.
In recent years, the World Bank, too, has emphasized the detrimental impact of
poverty on the health of people in developing countries and required
governments to "pursue sound macroeconomic policies that emphasize reduction of poverty" as a
"central" means of achieving "good health".[10]
In line with such arguments, it is today
taken as axiomatic by a growing number of international development
agencies and governments that the proper assessment, development
and implementation of equitable health programmes in response to
the humanitarian and social needs of the community is a central responsibility
of any government. By contrast, failure to provide
accessible health care, discrimination against women
or minority ethnic or religious groups in the provision
of health care, ill-treatment of prison inmates, or failure to provide adequate programmes in vital health areas, such as maternal welfare or HIV/AIDS, can all constitute the most fundamental violations of human rights.
A crucial aspect of this broad approach to
the right to health is the increased emphasis placed on preventive
aspects of health care rather than on medical treatment itself, a
trend also advocated by the World Bank.[11] According to WHO estimates, for example, half a million women die around the world every year from avoidable pregnancy-related causes, of whom 90 per cent live in developing countries.[12] Similarly, as Medecins Sans Frontieres
(MSF), a leading NGO in the health field, has pointed out, the
great majority of deaths occurring in children under five each year
are "avoidable mortality": that is, deaths from preventable or
treatable illnesses, such as malaria, diarrhoea,
measles, malnutrition or respiratory infections.[13]
For this reason, the Plan of Action adopted
by the 1990 UN World Summit for Children targeted the
"health, nutrition and education of
women" as the key to reducing the shockingly high rates of both maternal and infant mortality in many parts of the developing world. Indeed, access to information and the right to know, which are guaranteed in Article 19 of the Universal Declaration of Human Rights, constitute a vital basis of preventive health care.[14] Communities and citizens need basic information to make
informed choices over everyday health issues such as
birth spacing, for example, as well as to understand how
they can avoid the risks of illnesses such as HIV/ AIDS or cholera.
At the same time, for the supply of such
information to be truly effective, providing public access to health
care is not enough. The right of public participation, which is also
stated in the UN Declaration on the Right to Development[15], must be guaranteed in an accountable
system of health management, where independent data collection and efficient
monitoring of health programmes and practices are permitted as democratic
rights. As with many other health failings in
the country, the denial of such a system is a problem not only confined to
Starvation, disease, poverty, injury,
genocide and other gross human rights violations arising out of armed conflict
are perhaps the most extreme health emergencies that, all too frequently, have
been concealed by censorship. But a host of other grave health issues also threaten the state of global health and continue to be under-documented and under-reported, from the pandemic spread of HIV/AIDS and the
resurgence of tuberculosis in the past 15 years to reproductive health issues and other such perennial problems as drug abuse, cholera and malaria. Yet, despite this bleak picture, many physicians are confident that a growing number of health problems — including virtually all infectious or parasitic diseases — are either controllable or can be prevented altogether by a combination of education, access to information, diagnostic capacity, the availability of modern medicines and
treatment, and the financing of relevant health programmes.[17]
Tragically, although
Many of the gravest issues affecting the health of
In recent years, however, the sufferings of
the Burmese peoples have undoubtedly been compounded by the government's social and economic reforms. For while the SLORC's
"market-oriented", "open-door" economic policies
have clearly brought new prosperity to certain sectors of the community
(especially traders and families of the ruling
elite), a growing number of health problems have been observed by medical practitioners in different regions of
the country. Opposition groups argue
that the SLORC's economic and development
reforms have been ill-planned, discriminatory and often simply exploitative, causing many families to lose their
traditional livelihoods or lands.[18] For example, many doctors believe that, in several parts of
On the national scale, UNICEF has also recorded a recent rise in malnutrition among children under three from
32.4 per cent in 1990 to 36.66 per cent in 1991 (including a rise from
9.2 to 11.19 per cent severely malnourished), and in 1991 raised the estimated
prevalency rate of stunting among school
beginners (which is indicative of past or chronic malnutrition) from 29.1 to
40.5 per cent.[19] The consequences of such nutritional neglect can also be
detected in the nationally high rates of
Vitamin A and iodine deficiency, which lead to poor physical and cognitive development. For example, UNICEF considers a goitre prevalency rate (caused by lack of iodine) of more than five per cent a "public
health threat", but among schoolchildren in the
Some of the most extreme examples of new health problems in Burma today can be seen in the boom town mining communities of the Kachin and Shan States, where hundreds of thousands of people from all
over the country have rushed in the past few years in the hope of striking it
rich. In the malaria-infested jade-mining region at Hpakhan or the ruby mines at Mongshu, some doctors have made private fortunes
providing personal health care for those who can pay, but for most local
inhabitants there is little health provision at all. For many years, foreign
journalists and international health organizations have been barred from all
such sensitive regions of the country. But recent travellers report that intravenous drug use, prostitution and the
closely-attendant spread of HIV/AIDS are all
flourishing against a deadly backdrop of
ignorance and social crisis that desperately reflects the changing pressures and patterns in modern life.
In contrast to this evidence of neglect,
since assuming power in 1988 the SLORC has belatedly shown some awareness of the
responsibilities of government for the protection
of health rights in
Domestically, too, the SLORC has appeared to show greater interest in
addressing certain health issues than did its predecessor, the Burma Socialist
Programme Party (BSPP) government of General Ne Win (1962-1988). A number of
basic health rights had been officially recognized under the BSPP's 1974
Constitution, including the "right to medical treatment" (Article
149), the "right to rest and recreation" (Article 150), the right to
"enjoy benefits for injury due to occupational accidents or when disabled
or sick or old" (Article 151), and "equal rights for women"
(Article 154). The 1974 Constitution has been suspended since 1988. However, both
the duties of government and the rights of the people to information and
participation appear to have been further recognized at the National Convention
in
The actual timetable for introducing
Although the political process remains
deadlocked, the SLORC has, over the past few years, taken some
steps to introduce social and economic reforms. In the
health field, a National Health Committee has been set
up under the SLORC Secretary-One, Lieutenant-General Khin Nyunt,
to co-ordinate activities between the different government ministries and health departments. In the language of their deliberations,
the influence of different UN agencies is often clear. The cornerstone of
current health policy is
And yet, despite the declaration of such
important goals, many medical practitioners and international aid
agencies contend that the overall health and
humanitarian situation in Burma has either not improved
or has actually gone from bad to worse over the past decade. The ICRC's withdrawal from
But, undoubtedly the most serious humanitarian questions have been
raised by the continuing work of the UN Commission on Human Rights and its Special Rapporteur to
On 5 December 1995 the UN General Assembly
also demonstrated its continuing concern about a wide range of human rights
and humanitarian issues when it urged the SLORC, by consensus resolution, to "ensure full respect for human rights and fundamental
freedoms, including freedom of expression and
assembly", as well as to "put an end to violations of the right to
life and integrity of the human being" (Clause 11). In
January 1996, too, the European Commission declared it had received sufficient allegations of human rights violations that are contrary to International Labour Organization (ILO) Conventions and "International Humanitarian Law" to begin a formal
investigation into forced labour in
However, despite this growing body of
international evidence and condemnation, the SLORC has continued to
reject all criticism and deny any wrongdoing. Like certain other
Asian governments facing international criticism over their
violations of civil and political rights, the SLORC chooses to
invoke a different definition of human rights, a definition that gives far
greater priority to the collective economic and social well-being
of the population in general rather than respect
for the basic human rights of individuals. Speaking at the University for Development of National Races in February 1995, Senior General Than Shwe, the SLORC Chairman, described the relationship between different human rights in the following terms:
It is
regarded that food, clothing and shelter needs are the
most basic human rights for mankind to survive. It can
be said that once the basic human rights of the
people are met, there is no difficulty to fulfil other
human rights.[29]
Such arguments have also been advanced by SLORC officials in the international community. According to U Aung Aye, who led the
Human rights cannot be enjoyed in a
vacuum....Our concept of justice is not only justice in its legal sense but
also social, economic and political justice.
Few observers would disagree that there is a
close interdependence between social and economic rights and civil and political rights.
Indeed, one argument made in this report is
that violations of a wide range of
human rights — including freedom of expression and information, torture,
extrajudicial execution and forced labour — have an important bearing on the
health of the population. Yet, to date, the SLORC has steadfastly
refused to investigate any specific reports of human rights violations, despite
the repeated criticisms of the UN General
Assembly. In its most recent reply to the UN Special Rapporteur to
It would thus appear that, although all
sides in
Chapter 3
THE HEALTH SYSTEM IN
As in other state sectors, there has long been a yawning gap between the reality and rhetoric concerning the
provision of health care nationally
in
In the absence of other sources of information, health analysts have been largely dependent on official government reports and statistics which, ever since General Ne Win seized power in 1962, have
consistently depicted an expanding and progressive medical system. On paper at least, a comprehensive health system was built up during the BSPP era with large hospitals, dispensaries and a variety of specialist health centres in the main towns of all of
Since 1988, in response to the SLORC's moves towards a "market-oriented" economy, a number of new initiatives have been mooted
by government servants in the Ministry of Health. Many of
these would appear to mark a distinct break with the
past. Emphasis, for example, is now officially given to the role of
"community organizations", the return of
foreign NGOs to
However, as opposition groups point out, many
of the structural mechanisms and working practices from the
BSPP era have been maintained. The BSPP's third "People's
Health Plan" of 1986-1990, for example,
continued uninterrupted by the momentous events of
Despite a legacy of such inertia and
military control, there can be little doubt that the growing involvement of
foreign aid workers in
Many of
In many respects, Burma today displays the
classic characteristics of "strong societies" but a
"weak state", where the authorities have been unable to achieve — or countenance — effective action across all
social and ethnic sectors.[34] In government-controlled areas, there are, in
fact, four different — although overlapping — systems of health provision: public, private, traditional (or indigenous) and military.
But it is the public sector, upon which most
urban inhabitants depend and which had, in theory, been
freely available to all, that has come under the
greatest pressures since 1988 and which is losing patients most rapidly to the other sectors.
The political pressures in the state sector
are examined below (see Chapter 5), but health workers point to
two major areas of failure which permeate every region
of the country: chronic under-funding, and a neglect of
health education and the preventive aspects of health care. Many of the most obvious failings can be seen in government
hospitals. As one international health worker privately explained to ARTICLE 19: "Unless you have money, public hospitals are the next step to the grave."
As a result, over the years there has been a
constant exodus of qualified doctors from the public sector —
either to go abroad or, more recently, into other
occupations or into private medical practice in
As
Against this background, the second health
sector in
Concerns over the methods of private doctors
are, in general, more to do with the equity and ethics of
treatment than with its quality, which remains
relatively high (see Chapter 4). This is also largely the case with the third main health sector in
However, over the past decade many doctors have become increasingly concerned over the numbers of untrained "quacks"
operating on the fringes of modern medicine and
the private market, who use the failures in the
national health system to take advantage of the sick and needy. In
The tragedy, as many hospitals in
By contrast, the final health sector in
Brigadier Kyaw Win, for example, who was
formally General Ne Win's personal physician, was
widely regarded as one of Asia's top malariologists before his recent posting as Ambassador to Canada. In addition, the SLORC has established a
Nevertheless, despite better provisioning in
the military health sector overall, many soldiers in the ranks
privately complain that military health care is not evenly spread and
does not always extend to their families. Malaria,
for example, continues to inflict a steady casualty rate
among young soldiers stationed in the war zones, with dozens of fatalities annually. Although soldiers are supposed to be supplied with prophylactic medicines, both health education and testing facilities in the field are often extremely poor.
In summary, then, all four sectors within
the national health system face a host of critical problems during
an era of social uncertainty and political transition,
which many doctors and health workers are only too
anxious to address. Many doctors, for example, believe that it is impossible to tackle properly such everyday health problems as malaria, AIDS or tuberculosis while so many different and unrelated medical practices or systems exist around the country. In addition to the problems of diagnosis and treatment, drug resistance and infection can very quickly spread.
Very belatedly, the need for new strategies and effective integration between the different sectors was apparently recognized by the Health Ministry in the 1993 National Health Policy. Although dismissed by opposition groups as government public relations, this
pledged in Clause 5 to augment "the role of co-operative, joint ventures, private sectors and non-governmental organizations in delivery
of health care in view of the changing economic system". In another
overdue recognition of need, Clause 12 of the National Health Policy also promised to expand national health services for the first time to the border areas, following the cease-fires agreed between armed ethnic minority groups and the government (Chapter 6.1).
Then, in another policy shift in September
1994, the SLORC took the first steps towards abolishing the
system of theoretically free health care that had existed in
In essence, the new scheme consists of a list of 23 items and medicines that local health authorities can sell
to raise revenue to subsidize other
treatment and running costs. Typically, however, the new system has yet to be
properly explained to health workers or reported in the state-controlled media
to the general public. As a result, different prices and practices have been
introduced in different hospitals in different parts of the country, causing
many doctors to over-prescribe drugs which may be unsuitable but are plentiful
(because they are on the list), while more apposite cures are
unavailable. The concept of charges also appears to be becoming mandatory, with
a Caesarean operation, for example, now
costing 6,000-8,000 kyats in many hospitals after all the necessary
medicines and materials have been purchased,
leaving many poor families with the bleak choice between the possible death of a loved one or bankruptcy.
Equally serious, this emphasis on revenue and costing within the health system
continues to push doctors in the more lucrative direction of treatment and the curative aspects of medicine rather than education
or preventive health care.
Access to medical treatment is, of course, essential, but many doctors and health workers maintain that education
is the cheapest but most neglected
health reform that is needed in
______________________________________________________________________
Chapter 4
HEALTH IN A SOCIETY UNDER CENSORSHIP
As
In the state media, although health is a
common topic, no comment is ever permitted which might imply
any neglect or failing by the authorities. The state-controlled New
Light of Myanmar, in particular, often carries news
agency reports from international organizations such as
the WHO or UNDP, but these are generally concerned with health issues at the global level and do not illustrate actual
health conditions in Burma.[44] Instead, local health news consists largely of lists of prominent
military, governmental and, on occasion, foreign health figures who have
attended various hospital openings, graduation classes or seminars.
Some attempts to address health issues
within the country have been obvious propaganda. For example, a recent trilogy
of articles in the New Light of Myanmar on
"Indices of Progress in Myanmar" were studded
with graphs showing improvements in the health sector at almost Olympian
levels, ostensibly demonstrating "that the takeover by the SLORC was aimed at the common good of the country".[45]
For a reader unfamiliar with
There should be no doubt, too, that there
are many public doctors and health officials who try to react as
best they can to any medical emergency within the
limitations of the present public system. On
However, many local health workers and opposition groups complain that the occasional prominence given to such headline stories can flatter to deceive over the real state of national health provision.
Sudden emergencies may be covered, but the majority of
ongoing health issues continue unreported and unrecorded in
any informative way for
As a result, after over three decades of military
rule, the state-controlled press shows little sensitivity to local issues, and
for many years has failed to cover health conditions
in vast areas of the country, especially in ethnic
minority regions where local language publications
have been restricted.[47] In recent years UNICEF has produced various health
materials, such as Facts for Life, in Jinghpaw Kachin, Sgaw Karen, Mon, Shan and several other minority languages, but
distribution is limited, and local communities and writers face many obstacles before they can publish any materials themselves. (A number of versions of Where there is no Doctor, by Dr David Werner, have
also been translated into ethnic minority languages, including Karen and
Kachin, but these have mostly been distributed from territories controlled by
armed opposition groups.)
At the national level, too, health education is grossly under-resourced
and many government staff are unmotivated. As a result, people across the country are ill-informed and have little access to essential information on a broad array of vital issues — from the high
incidence of malaria in border regions to such common medical problems as malnutrition, hepatitis, snake-bites, complications arising
from backstreet abortions and intestinal
illnesses (including both dysentery and cholera).
Medical practitioners believe that some health problems, such as malnutrition, are neglected because they are an embarrassment, but others, such as cholera, are politically sensitive to the government because they are deemed to draw the international spotlight to the government's failings. In particular, all countries around the world have faced serious cultural, educational and medical challenges in
confronting the issue of HIV/AIDS, but in
In many respects, Burma thus presents a
classic case not simply of what the act of censorship deliberately
represses or excludes but of how an endemic culture of censorship and
restrictions on freedom of expression can prevent
vital health issues being explained or even discussed or reported. An obvious
but long-standing example of this is the often
low take-up rate of public services, even where they have been provided. But, as UN agencies have increasingly found, although traditional beliefs are sometimes responsible, this is frequently due simply to a lack of public education and understanding of what is available.[48]
The resultant lack of both individual and
community awareness of many common, but serious, health problems
in
Another much neglected area of health care is the plight of
Of similar concern are the country's many
leprosy sufferers.
The lack of national awareness, then, of most
of the above health problems can largely be attributed to a
combination of poor education, press inertia and apparent
governmental indifference. The absence of reporting on
many other health problems, however, results from deliberate censorship.
This is undoubtedly most blatant in the
reporting of war and humanitarian issues. For many years, the
military government has strictly suppressed all news of casualties
as well as reporting of other human rights and
humanitarian issues which have a bearing on health, such as forced labour or the treatment of prisoners (see Chapter 6). However, except for human rights abuses, many medical practitioners do not believe that military officers have any obvious reason for suppressing health news — except largely one of pride. In this, doctors must also take their share of blame for failing to report problems. As one health official privately explained, "The Tatmadaw rules
the country just like the Burmese kings. They had a
saying: 'Make a big problem a small problem, and make a small problem
disappear.' Everyone is fearful of criticism and no one wants to
admit mistakes."
Evidence of such fear of failure or criticism can be seen in many quarters today. One example occurred during an outbreak of cholera in several townships in the Rangoon Division in early 1993. Foreign diplomats say the outbreak was never officially publicized and that poster campaigns were discouraged since it was feared they might give
international visitors to the country a bad impression of
However, perhaps the most contentious area
of censorship and misreporting on health issues in
Since 1988, the same doubts about the accuracy of government statistics have continued. As one international consultant wrote in a recent report to the UNDP in
Nonetheless, if many aspects of government
and military spending remain shrouded in mystery, there can be
little doubt that increasing international scrutiny
of
Apparent recognition of this need to improve
basic health data came with the announcement of the 1993-1996 National Health
Plan, when the reliability of national health
information was for the first time officially questioned
during a workshop by government health workers:
Monitoring and Evaluation were identified early
... as weak spots in the management system .... The participants identified the information from the peripheral health units as being incomplete, inaccurate, patchy and unreliable for monitoring and planning purposes.[58]
Since the publication of the National Health
Plan, a number of failings in the health and
educational sectors have been discreetly voiced in government reports. For example, the massive educational underachievement of
Critics of the SLORC, however, allege that
government officials, rather than taking necessary actions,
are simply becoming more adept at regurgitating UN development
language. Indeed, it is in the background papers and
reports of the UN agencies themselves (notably UNICEF and
UNDP) that the underlying health problems are most explicitly stated. To date, the government has taken few substantive
steps to address most health issues.
For the moment, then, huge doubts must
remain over the quality of basic health information on which current
health planning and expenditure are officially based. As with all
health statistics in
This massive rise in the IMR has been explained by the Central
Statistical Organization of the Ministry of National Planning and Economic Development, which has responsibility for collating all such social and health data, as reflecting improved statistical methods. According to this explanation, the earlier rate was incomplete because it was based largely upon urban statistics, while the new figure is derived from a broader statistical base. But one public health worker who was involved in the new survey has privately told ARTICLE 19, "We could no longer hide the truth." Even more confusingly,
while the new 94 per 1,000 live birth figure is
recorded for 1993 in the latest Health in
Myanmar report, a figure of between 47.5 (urban) and
49.6 (rural) is provisionally stated for 1994, suggesting that the authorities might well be preparing to scale the IMR dramatically downwards once again.[59]
Not surprisingly, many doctors warn that the
reliability of any adjusted figures produced by the government should be
treated with great caution. In the case of infant
mortality, there are many variations in estimates of
the IMR in different localities, which reflect both the paucity of governmental outreach and the very different health conditions in different parts of the country. For example, doctors working
with Medecins Sans Frontieres (France) have estimated the IMR at around 200 per 1,000 live births in war-torn ethnic Karen regions along
the Thai-Burma border while, by some estimates, the
figure in upland areas of the eastern Shan State could be as
high as 300 per 1,000 live births.[60] Towards the other end of the scale, and
despite the many local health problems, in some of the new towns
around Rangoon health workers have calculated the IMR in these
areas as being below the 1993 national average — at closer to 65 per 1,000 live
births.
Finally, it needs to be stressed that simple
concentration on data collection and the reliability of statistics
can be very misleading in judging the overall state of health emergency,
provision and delivery in Burma. After recent tours of the country,
a number of international health and development
workers have privately said that in some areas the
health infrastructures are either non-existent or so poor that official statistics simply cannot reflect the real conditions of health
in the community. In many rural areas, for example, cholera and dysentery epidemics, which take hundreds of lives, still go unreported or
uninvestigated inside
It's all very well for health officials to use statistical projections to declare a state of emergency over the spread of AIDS
— and they may well be right. But for many families and
communities it will still be malaria, conflict or
malnutrition and poverty brought on by everyday social injustices and
hardship that will continue to take the greatest
toll of life. However there is no sense of
governmental or international urgency over issues like
these.
Indeed, many local health workers already feel that the tendency
of international donor agencies to focus on
the high-profile issue of HIV/ AIDS could help to marginalize vulnerable
groups and other longstanding health
problems even further. "Nowadays people will train in AIDS but
nobody wants to work in a leper colony or work with the blind or handicapped," one physician complained. "Doctors
will only work where they know there
are good salaries and funds."
Another concern expressed about official statistics is that they do not reflect the quality of health care that is
actually provided. One veteran
official in the Burmese health system privately made a long list of
criticisms:
The way health statistics have been used in
official reports is unethical and misleading. The
survey questions asked to produce such data never reveal the true
picture. There is no proper monitoring or feed-back. For example, there is
always a lot of statistical concentration or
publicity about the opening of new
clinics or hospitals, but it is never asked or disclosed whether there has been a better rate of diagnosis, more doctors employed or patients
seen, a better rate of treatment, a better rate of patient satisfaction or an improvement in the general
standards of health in the
community. This is what we should be aiming at, but no one dares openly
talk or write about it.
A similarly neglected issue is the manner in
which the central government in
Finally, perhaps the most overlooked area of
censorship and health care are the health rights of the Burmese peoples
themselves, especially the right to information. In a health system where
corruption is widespread and private practice
booming, many people have increasingly fallen victim
to a pernicious combination of press control and
exploitation by unscrupulous doctors who do not hesitate to conceal information as well. Explained one physician:
The problem is often not so much one of censorship in itself, but a complete lack of information or fora for citizens to discuss health issues which they need to know
about in their daily lives. This means that they are totally vulnerable, not
only to preventable illnesses or diseases such as malaria,
HIV or cholera, but also to doctors in whom they put
their trust. Many doctors will always direct them
in the direction of the private sector where they
can make lots of money through treatments and drugs.
The patients, however, are unable to judge the
diagnosis, context or quality of any treatment they
receive.
Although there are many incidents of individual generosity by doctors, misdiagnosis and poor treatment are common. Equally serious is the uncontrolled sale and mishandling of medicines by both doctors and middlemen who make their living out of this trade. The country's
National Drug Law has never been strictly enforced. In fact, the state-owned Burma
Pharmaceutical Industry (BPI) is one of the few governmental institutions that has historically enjoyed a high reputation
for quality in the country, but production is generally limited and most medicines are always in short supply. As a
result, in the days of the BSPP a thriving cross-border trade in black
market medicines developed, which was estimated to account for over 50 per
cent of all drugs on sale in the country.[62]
Under the SLORC's market-oriented economic
system, parts of the border trade have become technically
legal. However, problems in both commercial distribution and sales persist
with exactly the same negative implications for patients. No health regulations
are visibly employed to govern the
prescription or labelling of medicines. On sale in the markets are many
fake products and out-of-date medicines, as well
as drugs bearing instructions in only Chinese, Thai or Indian languages, which few medical practitioners — let
alone ordinary inhabitants — can read. Contraceptive pills, for
example, are often sold in loose strips, devoid of any instructions or
packaging. Moreover such unsound medical
practices are not only confined to the private sector, which accounts for the
bulk of this trade. One confidential survey in a public health centre
recently monitored dispensing practices according to WHO standards and found them "far from rational";
indeed, none of the medicines at the clinic were labelled with
prescription instructions at all.
The discovery of such malpractice can place international agencies in a difficult moral dilemma. In a system where little objective or investigative reporting has ever been allowed, foreign organizations
can be quickly seen as troublemakers if they publicize their findings, causing
embarrassment or arousing resentment among government
officials and local doctors alike. As a result, the need for publicity to spread awareness is often tempered by
self-censorship and tact in order to
be allowed to continue working and to try and produce long-term results.
One issue, however, on which public information campaigns are urgently
needed concerns the dangers of intravenous treatments carried out in unhygienic conditions, particularly in a context of
rising HIV-infection. Initially
introduced by doctors as another means of selling more medicines, intravenous treatments, especially drips and vitamin
injections, are extremely popular. Chinese-brand injections, especially B-Complex or B-12-1,000, are commonplace
and are desired by patients as a
means of boosting energy levels during illness. Standards of hygiene,
however, leave a lot to be desired in even public
health centres where new or sterilized needles are always in short supply, but the fashion for giving vitamin
injections is also endemic amongst
the many unregistered practitioners working throughout the country.
In the
Like many health issues in
Chapter 5
POLITICAL RESTRICTIONS ON MEDICAL PRACTITIONERS
Doctors and other health workers have traditionally formed one of the most respected sectors in Burmese society. Doctors, however, who have participated in opposition political activities, or who have spoken out against the government, are among those whom the security
services have particularly targeted for repression. In addition, the medical
profession as a whole suffers from the severe restrictions on freedom of expression and association that also apply to other occupational groups in
In the parliamentary era of the
1950s, although there were many failings within the national health system, hospitals and physicians in
Medical practitioners date the general
decline in specialist standards to the military's
seizure of power in 1962 and the beginning of 26 years of isolation under
General Ne Win's
Most emigrant Burmese doctors admit to having left for either financial or political reasons which, until recently, strictly precluded
their return.[63] However, many also felt frustrated by the fall in medical training standards that followed the nationalization of all schools and
colleges in 1964. In particular, the abolition of the Chair of English at
Finally, this damaging discrimination
against English was ended in 1980 after one of General Ne Win's own
daughters was rumoured to have failed
entrance tests to begin postgraduate studies in medicine abroad. The damage, however, had already been done
to a whole generation of students.
Although some excellent medical staff have remained in the country, there is a general consensus that educational standards have never recovered. Certainly,
insufficient doctors or nurses were
trained to staff the expansion in health care that was attempted under the BSPP. On paper, many of the Health
Ministry's goals looked sound but, other than increased immunization,
few targets were successfully reached due to a combination of ill-conceived
policies and the continuing state of
political crisis in the country.
Since 1988, the social and political
pressures on medical practitioners have greatly
intensified, as they have for all other public servants. Young doctors and
medical students were highly active in the democracy protests of 1988. A number
of undergraduates from Rangoon Institute of Medicine No.2, for example, were
in the line of fire when troops began shooting at demonstrators
outside the
In government-controlled areas, meanwhile, the political pressures on
medical practitioners have been relentless. Like all universities and colleges
of higher education,
However, perhaps the most extraordinary
crack-down on doctors and other public health workers occurred
the following year. Following student demonstrations at Rangoon
University in December 1991 in celebration of the award of the
Nobel Peace Prize to Aung San Suu Kyi, in early 1992
the SLORC ordered all government doctors to attend
"re-education" courses run by the Military Intelligence Service at the former BSPP training camp at Phaungyii, where civil servants had also been made to attend political training classes under the previous government. Nearly 3,000 — a quarter of the country's doctors — attended the first six courses during 1992-1993. Dressed in military uniforms, they were required to attend classes aimed at providing "doctors with nationalism", "acceptance" of
the military's leading role, "management of public health
affairs" and the "observance of
discipline".[66] Yet again, the political behaviour and attitudes of health workers were
closely monitored and, following the completion of these courses, colleagues reported that a number of doctors and other health officials were abruptly dismissed.
After seven years of such constant scrutiny and political observation,
many doctors say that the triple pressures of political censorship and poor working conditions and low wages have left even the most committed of the country's public health workers a very demoralized
force. As in other walks of civil service life, a common saying among health workers runs: "Ma loke — Ma shoke — Ma pyoke: no work — no problems — no sackings." Moreover, while there is no evidence that doctors have been prevented from carrying out their daily medical work, there is a deep-felt view that, like other intellectuals, writers and academics, they are especially vulnerable to being targeted
by the government because of their social status and
potential influence should they dare to express dissent.
Explained one doctor, "It's OK as long as
you just do your job and keep away from politics. But if you are a doctor and do get involved, then you are in immediate danger."
There is considerable evidence to support
such claims. Doctors have been prominent amongst opposition
figures arrested or imprisoned by the SLORC since 1988. Dr Zaw
Min, for example, who participated in the 1988 protests at Rangoon
University and Rangoon General Hospital, was arrested in July 1989
and subsequently sentenced to 20 years' imprisonment with hard labour (since
reduced to 10) under section 5(j) of the 1950 Emergency
Provisions Act for allegedly distributing seditious
anti-government literature and illegally organizing
workers. Like another physician who was also arrested,
Dr Maw Zin from Paukkhaung, he was suspected of involvement with the outlawed Communist Party of Burma.
The main security pressures, however, have been focused on medical supporters of the National League for Democracy. In an apparent act of revenge, Dr Tin Myo Win, an NLD central committee member and surgeon at Rangoon General Hospital, was arrested in August 1989 on vague security charges for what many fellow professionals believe was his active support for the 1988 democracy movement. Dr Win was eventually released in 1992 but many more NLD supporters, including several well-known medical figures, have continued to be arrested and imprisoned. On
In another clamp-down in October 1993, two
more well-known medical figures, Dr Aung Khin Sint, also an
NLD MP-elect and medical writer, and Dr Ma Thida, a writer
and surgeon at the Muslim Free Hospital in Rangoon, were both sentenced to 20
years' imprisonment after being convicted on a variety of
charges, including under the 1950 Emergency Provisions Act, the 1962
Printers and Publishers Registration Law and the 1908 Unlawful Associations
Act, for allegedly writing "illegal" literature in support of the
NLD and distributing it during the SLORC's National Convention in
Rangoon.[68] After months of pressure by the UN Special Rapporteur to
However, perhaps the clearest evidence of
the political harassment of a medical practitioner has been the
experience of Dr Khin Zaw Win (also known as Kelvin). A qualified
dentist and former UNICEF worker, Khin Zaw Win attended the UN
Conference on the Rights of the Child in
Khin Zaw Win's only "offence", it thus appears, was that he had tried to speak out. In a conference paper distributed in
Understandably, there are now signs of ideological fatigue, a vacuum so to speak. The censorship that has prevailed at all levels during the last three decades has been terribly effective.[70]
The use of such smear charges against
prominent individuals accused of expressing
anti-government opinions is not unusual. The most striking example also occurred in the medical field, in 1989, when U Win Tin, vice-chairman of
Finally, in addition to the repression suffered by individual doctors and medical practitioners who participate in opposition politics, the
profession as a whole suffers severe restrictions on its right to organize and
the right to freedom of association. Independent trade union activity, which had briefly revived during the 1988 protests, was immediately banned following the SLORC's assumption of power. Instead, health workers who want to involve themselves in voluntary medical associations are largely restricted to three organizations, all
of which — although described as "NGOs" - -
have close links to the Health Ministry and government. This creates particular
problems for foreign NGOs and UN agencies working in
After years of political repression and malaise, the question of indigenous NGOs
in
Founded in 1949,
This has largely left the non-governmental health field to Burma's two other main "NGOs", the Myanmar Red Cross (MRC) and the Myanmar Maternal and Child Welfare Association (MMCWA), both of which have even closer links with the government and Ministry of
Health. With over 180,000 volunteer members, the MRC is supported by public donations and government funds and is supposed to have branches in each of the country's
319 townships. Here its primary role
is disaster preparedness and first aid to complement public services. Similarly, the MMCWA is also trying to establish branches in townships throughout the
country. As it expands, one of its
main tasks will be to work with local Township Medical Officers, under the
Ministry of Health, to manage many of the country's Maternal and Child Health Centres.
That there are many committed doctors and health workers in both organizations is not in question. Doubts, however, have been frequently raised over the neutrality and responsibilities of these organizations in the current political environment. For example, in over four decades of armed conflict, there is no evidence of the MRC ever operating as a neutral, humanitarian agency among civilian communities in armed opposition areas. By contrast, in 1989 the MRC became involved in the controversial repatriation of several hundred
student refugees from
Likewise, even the treatment of children is not free from political argument, and the MMCWA's NGO status is also often questioned. Its joint General-Secretary (a doctor) is the wife of the SLORC Secretary-One,
Lieutenant-General Khin Nyunt; the President is the wife of Colonel Pe Thein, the former health minister; and the Vice-President is the sister of the late Dr Maung Maung, a leading BSPP functionary and, originally, one of Ne Win's chosen successors as party chairman.
Equally critical, at a time of historic social and economic change, many people believe that the obvious favouritism shown by the SLORC towards the MMA, MRC and MMCWA is inhibiting the development of other independent NGOs, which could more accurately reflect the aspirations of the different ethnic peoples of
In response to such concerns by donor governments, in 1992 the UNDP's Governing Council decided to reorientate its programmes in
In the ethnic minority war zones, too, the issue of NGOs and community participation is equally controversial. Here, central government outreach has long been resisted; but, in agreeing to ceasefires, many armed opposition groups have told their supporters that economic development, the legalization of indigenous NGOs, and the construction of a new system of public health care are all activities which can help cement the peace. Yet, the SLORC has been reluctant to authorize any new projects in which locally-based community or opposition groups are actively involved. Instead, international aid agencies are required to negotiate first with the SLORC and relevant government ministries over access at the community level. To date, no major development project has been begun under ethnic minority auspices.
The result is widespread dissatisfaction with the quality and level of access to health care that has been provided so far. The reality
falls far short of the image of new building
programmes for health which are constantly projected
in the state-controlled media. The SLORC, for example, claimed to have
constructed over 30 hospitals and 66 dispensaries
under its Border Areas Development Programme between 1989 and 1993 alone.[73] However, Kyauk Nyi Lai, Secretary-General of the United Wa State Party, which signed a cease-fire with the SLORC as long ago as 1989, has provided a markedly different picture:
The SLORC claims it helps the Wa but, for
example, when it builds a hospital, there is
neither a bed nor a single doctor. And when I ask the
Burmese why they do that, they answer "we have
our own problems".[74]
Fundamental problems, therefore, lie ahead
concerning the rights to freedom of association, participation and
expression if local communities and groups in
For the present, then, it is only the MMA, MRC and MMCWA, all of which maintain national structures, which are the main NGOs able to function in the health field. To try and address this issue, in
January 1996 the NLD unveiled a development strategy
whereby international agencies, such as the UNDP,
should work with the NLD as the only national organization in
To support this new policy, Aung San Suu
Kyi, General-Secretary of the NLD, attempted to institute
an official dialogue -both through correspondence and face-to-face
meetings — with leaders of different UN agencies responsible for development
and health. This prompted a furious reaction from the
SLORC. After Suu Kyi met in February 1996 with Giorgio Giacomelli,
Executive Director of the UN International Drug Control Programme (UNDCP),
the state-controlled New Light of Myanmar
accused him of conduct "incompatible with the status of a gentleman" and made a racist slur
against the British husband of Suu
Kyi:
While in
Shortly afterwards, a flight carrying the
head of the World Health Organization, was reportedly delayed without
explanation for two hours in Mandalay to prevent him
returning to Rangoon in time for a scheduled meeting
with Suu Kyi.
The SLORC thus appears determined to monopolize or control all contacts between
international agencies and representatives of the peoples of
Chapter 6
CONFLICT AND HUMANITARIAN CRISIS
6.1 The Backdrop Of War
Undoubtedly the most neglected area of
health care in
Until 1988, civilian casualties and the state of civil war in
Such estimates, however, do not give an
adequate picture of the degree of human suffering. In ethnic minority
areas, in particular, many local communities and
cultures have been badly afflicted, and across the
country there are countless disabled, widowed or orphaned children among all ethnic groups. Moreover, while General Ne Win's xenophobic Burmese Way to Socialism held sway, no independent
monitoring of the humanitarian situation was
permitted at all within
As a result, a systematic pattern of human rights abuses and breaches of
international humanitarian law has developed in Burma, in which the summary arrest, torture or extrajudicial execution of civilians have become commonplace, and humane treatment is rarely afforded to prisoners captured in the conflict. Over the years, vast areas of the country have been declared virtual "free-fire"
zones under a draconian counter-insurgency programme,
known as the "Four Cuts", which was
devised by Burmese army commanders in the 1960s to try and divide insurgent groups from civilian supporters.[83] All such practices, it should be stressed, are in
violation of Common Article 3 of the Geneva
Conventions (which applies to situations of internal conflict), under which all parties to a conflict are obliged to provide care to
both civilian victims and prisoners.[84]
Since 1988, this obsessive secrecy about the impact of some of
However, changing international awareness of the
scale of
All the cease-fires agreed to date, it should be emphasized, have been purely military, with no serious political issues discussed, while
the SLORC proceeds with its National Convention process in
Nonetheless, after a slow beginning, the
peace process has begun to gather momentum and, since 1990, the
first UN and other international visitors in decades have been
allowed to travel to several war-torn areas of the country.
Currently, 17 of the 20 largest armed opposition
groups in
Thus, with the SLORC's most recent
cease-fire with the 15,000-strong Mong Tai Army (MTA)
of Khun Sa in January 1996, the situation is
extremely delicately poised. As fighting comes to a halt, opposition groups and community leaders are hoping that the establishment of peace will allow serious attention to be paid to the many health and humanitarian problems caused by the war, including the welfare of refugees and the internally displaced, the effects of the indiscriminate use of land-mines, and the conscription of children as soldiers.[90]
Tragically, however, continuing injuries and casualties are still being
reported in different regions of the country, even in some areas where cease-fires
have been agreed. On
At the same time, there has also been no
let-up in reports of gross human rights violations where formal
cease-fires have yet to be agreed. In November 1995, for example, the UN
Special Rapporteur to