FATAL SILENCE?

Freedom of Expression and

the Right to Health in Burma


ARTICLE 19  

July 1996    


 

 

 

 

ACKNOWLEDGEMENTS

This report was written by Martin Smith, a journalist and specialist writer on Burma and South East Asia.

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 Burma. Such information was willingly supplied in the hope that it would increase both domestic and international understanding of the serious health problems in Burma. Under current political conditions, however, many aid workers have asked not to be identified.

 

©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 
Burma    

Chapter 3    The Health System in Burma                                 

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 Burma Students Democratic Front

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                  Burma Pharmaceutical Industry

BSPP              Burma Socialist Programme Party

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 Independence Organization

KNU               Karen National Union

KNPP             Karenni National Progressive Party

MMA              Myanmar Medical Association

MMCWA        Myanmar Maternal and Child Welfare Association

MNRC            Mon National Relief Committee

MP                  Member of Parliament

MRC               Myanmar Red Cross

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 America

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
Burma (Myanmar[1]). After decades of governmental secrecy and isolation, Burma was dramatically thrust into world headlines during the short-lived democracy uprising in the summer of 1988. But, while international concern and pressure has since continued to mount over the country's long-standing political crisis, the health and humanitar­ian consequences of over 40 years of political malaise and ethnic con­flict have largely been neglected. Indeed, in many parts of the country, they remain totally unaddressed.

 

There are many elements involved in addressing the health cri­sis which now besets Burma's peoples. A fundamental aspect, in ARTICLE 19's view, is for the rights to freedom of expression and information, together with the right to democratic participation, to be ensured. In a context of censorship and secrecy, individuals cannot make informed decisions on important matters affecting their health. Without freedom of academic research and the ability to disseminate research findings, there can be no informed public debate. Denial of research and information also makes effective health planning and provision less likely at the national level. Without local participation, founded on freedom of expression and access to information, the health needs of many sections of society are likely to remain unaddressed. Likewise, secrecy and censorship have a negative impact on the work of international humanitarian agencies.

 

Although not comparable to the crises in Rwanda or Somalia, modern-day Burma has one of the poorest health records and lowest standards of living in the developing world. At independence in 1948, the country was regarded as one of the most fertile and potentially prosperous lands in Asia. By the time of the democracy uprising in 1988, however, Burma had become one of the world's ten poorest nations. With an average per capita income of just US$ 250 per annum, today Burma is categorized by the United Nations (UN) as a Least Developed Country (LDC).

 

Health statistics can be notoriously unreliable in Burma and, by selective quoting, very different pictures of the national health situa­tion can be painted. With so little data available, health problems can be overestimated as well as underestimated. But among a plethora of urgent health issues, the following stand out as the legacies of decades of social and political neglect:

           Burma currently has one of the highest rates of infant and
maternal mortality in
Asia;

           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;

           Burma is the world's largest producer of illicit opium and heroin,
which has a grave health impact in both Burma and the

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;

           Burma has generated over one million refugees or internally-
displaced people as a result of civil war;

           Burma has over one million inhabitants who have been
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 Burma since 1988 have chosen health and education programmes as their first point of entry. For far too long, Burma's health and humanitarian crises have been allowed to continue, virtually unacknowledged and unreported, under a stifling blanket of governmental censorship and inaction. Indeed, so alarmed were they by the results of new field-surveys that, in 1992, officials of the United Nations Children's Fund (UNICEF) considered calling for an urgent campaign of international humanitarian relief to alleviate what they described as "Myanmar's Silent Emergency":

For a long time the state of Myanmar's children was perhaps one of the country's best kept secrets. Decades of self-imposed isolation, fabricated sta­tistics and the absence of social research and jour­nalistic inquiry had created a false image of social developments.... In fact, neither the outside world nor even the authorities inside Myanmar have an accurate or complete appreciation of the very seri­ous conditions in the social sectors.[2]

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, Burma has entered its third critical period of political and economic transition since independence in 1948. But, although the first international non-governmental organizations (NGOs) have been allowed to return under the SLORC's "open-door" economic policy[3], internal political repression has continued at a high level. In particular, the SLORC has never accepted the result of the 1990 gen­eral election, in which the National League for Democracy (NLD) won a landslide victory. Over the past eight years, thousands of de­mocracy supporters and NLD activists, including the party's leader Daw Aung San Suu Kyi, have been detained without trial or sentenced to prison terms for peaceful opposition to the SLORC[4].

 

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 Burma today is a direct outcome of 33 years of military misrule. How can any humanitarian problems be tackled without first addressing the root problems which are political?[5]

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 Rangoon. "As long as there is peace, we believe the political discussions can continue," stated Major-General Zau Mai, chairman of the Kachin Independence Organization (KIO), which signed a cease­fire agreement with the SLORC in 1994.[6]

Despite such conciliatory words, however, the tasks of social and political reconstruction now facing Burma are enormous. At a time of widespread poverty and economic uncertainty for the majority of Burma's peoples, the entire health system is in a state of crisis, reflecting the many years of governmental inaction and political stag­nation. Corruption and inefficiency are rife; censorship is pervasive; draconian political restrictions are enforced on all medical practition­ers; health information is scarce and often inaccurate; and large areas of the country remain inaccessible to independent health workers and still tentatively returning to Burma, in June 1995 the International Committee of the Red Cross (ICRC) decided to pull out of Burma altogether in protest at continuing restrictions over monitor­ing the health of prisoners and the lack of governmental co-operation with its humanitarian work (see Chapter 6.3).


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 Burma, the first part examines the underlying issues of health and human rights against the backdrop of the country's long-running political malaise. The second part then looks at three specific areas of concern: humanitarian emergency, AIDS and narcotics, and women's health. Each topic raises fundamental issues over the rights of all people to freedom of expression, and to freedom of research and information.

 

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 Burma


Burma today presents an acute example of the vital link between the realization of the right to health, freedom of expression and the protection of other human rights. Among international develop­ment organizations, research and analysis into this fundamental in­terdependence are still evolving: many of the ethical issues raised by modern science or public health law and practice are extremely com­plex. Nevertheless, although not always explicitly stated, the basic "right to health" has long been enshrined in a number of international human rights declarations and treaties. Pre-eminent among these is Article 25 of the Universal Declaration of Human Rights (UDHR), which states:

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 Burma. Over the years, as a recent investigation by ARTICLE 19 into reproductive health pointed out, many governments around the world have been able to "manipulate, suppress or fail to provide information", which has contributed to the ill-health or deaths of millions of people.[16]

 

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 Burma represents an outstanding example of the need to respect a broad range of human rights in order to protect health rights, substantive debate on these issues has scarcely begun. Burma today is suffering the consequences of five decades of political confrontation and over 30 years of military rule.

 

Many of the gravest issues affecting the health of Burma's peoples result from armed conflict. Since 1988, such inhumane prac­tices as torture, extrajudicial executions and "scorched earth" tactics by the government have been documented by international human rights organizations and given considerable publicity abroad (see Chapter 6.1). In this context, it should be noted that armed opposition groups have also, over the years, been responsible for many gross abuses that have had a negative impact on health and inhibited the development of more equitable systems of public health care.   

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 Burma, the continuing high incidence of such serious health problems as malnutrition, malaria, diarrhoea and various water-borne diseases can be directly attributed to governmental policies of civilian resettle­ment or "forced relocations" under various development or counter-insurgency programmes. Indeed, since the SLORC assumed power in 1988, over one million people are estimated to have been forcibly re­located in the countryside or moved from downtown urban areas to new satellite towns around Rangoon and other main conurbations (see Chapter 6.2). In some rural relocation sites, health workers have found over 50 per cent of children under five to be suffering from malnutri­tion. Along with poor sanitation and inadequate health infrastructures, malnutrition is a major, though largely unreported, factor behind the high rates of infant mortality in many communities.

 

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 Chin State a rate as high as 65 per cent has been recorded.[20]

 

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 Burma. Prior to 1988, under General Ne Win's isolationist "Burmese Way to Socialism", Burma was one of the world's most reticent signatories to international agreements and conventions. However, in one of many ambivalent steps taken by the ruling generals, from 1989 the SLORC government began to sign or acknowledge a broad array of interna­tional conventions. Prominent among these are the 1949 Geneva Conventions, the UN Convention on the Rights of the Child, the World Declaration for Nutrition, the Vienna Convention for the Protection of the Ozone Layer, and the UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, all of which contain important provisions relating to health and humanitarian issues.[21] In addition, the SLORC has for the first time entered Burma into a number of agreements that include other important health provisions with different international agencies or countries, including the UN International Drug Control Programme (UNDCP), the UN High Commissioner for Refugees (UNHCR), China, Thailand and Bangladesh.


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
Rangoon, which the SLORC convened in 1993 to draft a new constitution. This would appear evident from the 104 basic principles that have been drafted to date - for example, Principle 18 (a) and (b) declares: "The State shall earnestly strive to improve the education and health of the people; the State shall enact necessary law to enable the national people to participate in matters of education and health of the people."[22]

 

The actual timetable for introducing Burma's new constitution is contentious and uncertain. In November 1995, the NLD officially withdrew from the Convention in public protest at the many political restrictions and the lack of "freedom of discussion"; the Convention, Aung San Suu Kyi said, did not represent "the will of the people"[23] The SLORC, nevertheless, has continued to convene sessions of the Convention without the participation of the NLD, which has also been barred by the SLORC from further attendance.

 

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 Burma's National Health Plan 1993-96, which is based upon the goals of the WHO's "Health For All by the year 2,000". To support these objectives, a number of specialist programmes have also been set up, including the National Drug Policy (1991), National Population Policy (1992), National Health Policy (1993), National Programme of Action for the Survival, Protection and Development of Myanmar's Children in the 1990s (1993), and the National Plan of Action for Food and Nutrition (1994). Important targets in the National Programme of Action for Children, for example, are the halving of the rates of both infant and maternal mortality, immunization of 90 per cent of all infants, and provision of "access to information about and preventive measures against HIV/ AIDS to all at-risk groups".[24]  In another significant development, NGO and community-based approaches to health have also been proposed (see Chapter 3).

 

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 Burma in June 1995 was perhaps the sharpest indication of international concern over the government's approach to health and humanitarian issues in practice (see Chapter 6.3). All Western bilateral aid to Burma was also cut off in 1988 in protest at the violent manner of the SLORC's assumption of power. Then, in May 1992, in response to human rights concerns that aid was not reaching the people, the Governing Council of the UN Develop­ment Programme (UNDP) took the extraordinary decision to halt new funding for its Burma Country Programme for one year until a com­plete review had been undertaken to ensure that future projects would reach the "grass-roots level" in a "sustainable manner".[25] The result of these deliberations was the formulation of the UNDP's "Human Development Initiative" for Burma, which aims to improve the " people's welfare through participatory development involving com­munities and grass-roots initiatives".[26]

 

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 Myanmar. In a series of reports published since 1992, the Special Rapporteur has documented a disturbing background of gross human rights violations, all of which would have contributed to the poor health environment in the country, despite the recent spread of cease-fires between the SLORC and armed ethnic opposition groups. For example, while welcoming the release of Aung San Suu Kyi in July 1995, the Special Rapporteur's most recent statement to the UN General Assembly cited continuing evidence of summary executions, arbitrary detentions, torture, rape, forced relocations, forced labour for government development projects and forced porterage, in which conscripted citizens are compelled to work in "appalling living conditions".[27] The SLORC's formal health policies absolutely fail to address the impact of human rights viola­tions of this kind on the population's health.

 

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 Burma, with a view to suspending economic tariff privileges under the European Union's Generalized Scheme of Preferences.[28]

 

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 Myanmar delegation at the 51st session of the UN Commission on Human Rights in March 1994:

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 Myanmar, the SLORC simply dismissed all his allega­tions as "unfounded, emanating from anti-government sources and ter­rorist groups, with the aim of discrediting the Government as well as the Armed Forces of Myanmar".[30]

 

It would thus appear that, although all sides in Burma publicly say they recognize the need for social and political reform, for the moment freedom of expression and the important linkage between health rights and other human rights are not even on the national agenda.


 

 

Chapter 3

THE HEALTH SYSTEM IN BURMA


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
Burma. Few independent studies have ever been permitted and, until the recent cease-fires between the government and armed ethnic opposition groups, many regions of the country had remained strictly off-limits to international observers for decades. Even today, vast areas remain either officially forbidden or are inaccessible to outside agencies, especially in the ethnic minority states.


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 Burma's 14 states and divisions, as well as a system of local co-operatives.[31] Smaller hospi­tals and facilities were also developed, including maternal and child health centres, under the supervision of a qualified Medical Officer in each of the country's 319 local townships. Privately, however, govern­ment doctors admit that effective health provision never extended to much more than a third of the country. In part, this was due to govern­mental neglect and lack of resources. But it was also due, in large part, to the insurgencies. Even today it is still possible to find nurses and other health workers drawing government salaries in military garrison towns, who have never travelled into the countryside to take up their positions.[32]


Since 1988, in response to the SLORC's moves towards a "mar­
ket-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 Burma, and increased co-operation with different UN agencies.[33]

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 Bur­ma's "democracy summer" in 1988, and in 1991 was replaced by a series of new "National Health Plans", which followed virtually the same goals. An updated and more relevant National Health Policy was promulgated in 1993 (see Chapter 2), but — as in other walks of national life — doctors complain that military control over the top echelons of decision-making remains absolute. In consequence, the Health Ministry, which is headed by Vice-Admiral Than Nyunt, re­mains highly bureaucratic and slow to respond to the needs of the people. Indeed, much of the energy and influence behind recent changes comes not from the Ministry but from the National Health Committee, a powerful inter-ministerial grouping which is chaired by Lieutenant-General Khin Nyunt, the SLORC Secretary-One and head of the Military Intelligence Service. As an indication of the concentration of power in a few individuals in Burma, Khin Nyunt, who is regarded in ruling circles as a progressive within the SLORC on development is­sues, also chairs the government's Education, Foreign Affairs, Tour­ism and Border Areas Development Committees. Like Vice-Admiral Than Nyunt, however, Khin Nyunt is believed to have no formal medi­cal experience or training.

 

Despite a legacy of such inertia and military control, there can be little doubt that the growing involvement of foreign aid workers in Burma since 1988 has given a long overdue boost to the domestic and international recognition of serious health problems in the country. This has come about both by the continuing work of different UN agencies, which remained in Burma after the SLORC's assumption of power in 1988, as well as the arrival of the first international NGOs after 1991. In particular, following the SLORC's accession to the UN protocols on the Rights of the Child and the Geneva Conventions, the language appearing in official health reports has begun to fit more closely with international norms. However, it should be emphasized that the important ideals which are expressed in such reports come nowhere near describing the reality of human suffering or lack of adequate health or medical provision that exists in many parts of the country today.

Many of Burma's health problems are long-standing and can be dated back to previous governments. But medical workers in the field generally concur that, despite the publicity given to recent initiatives by UN agencies and foreign NGOs (especially relating to HIV/AIDS), for the majority of Burma's peoples both the health pressures and difficulties in finding access to adequate health treatment have increased since 1988 as the existing state system has begun to unravel.

 

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."

 

Burma still has many committed doctors and nurses, and there are many everyday examples of philanthropy. Many honest and hard­working practitioners are also very sensitive to criticism about health issues in Burma over which they feel they have no control. Neverthe­less, after years of under-funding and poor management, corruption has become endemic in the public health system, with patients often required to pay bribes or fees every step of the way — sometimes from the hospital gateman to even getting a bed. Essential medicines, too, are always in short supply, and for many years even those medi­cines which do arrive in the clinics and surgeries have been routinely, but illegally, sold off to black market or privately-run pharmacies that can be found in streets around many main hospitals. Although treat­ment is technically free, patients have been required to buy back from the pharmacies all medicines (and even cotton wool) that are needed for operations. In private, many hospital staff have freely acknowl­edged their involvement in such illegal sales; it is unpopular, for example, to be posted to work in hospital blood banks, since there is no access to medicines that can be sold. But in their defence, public health workers argue that their families simply cannot survive without raising extra sources of income. Doctors, for example, who are at the top of the public pay scale, have average salaries of just 1,500 kyats (US$ 15) per month.[35]

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 Burma. Throughout the country, despite a general expansion in primary health care over the past decade, there are huge gaps and con­stant interruptions in medical provision, making it difficult to sustain community health programmes. According to UNICEF, of Burma's 13,392 qualified doctors in 1993, only 4,998 were recorded in public service; the remaining 8,394 were working as general practitioners in the private (or co-operative[36]) sector; significantly, too, an estimated 80 per cent of government doctors also run private clinics, sometimes even during duty hours when they fail to turn up for their official work.[37] There is also serious under-staffing of other medical personnel, including midwives and nurses, and the former BSPP's Community Health Worker programme, which had given rudimentary training to over 30,000 volunteers, was recently discontinued.[38]

 

As Burma's 46 million population continues to grow rapidly, these changing working practices and health demands have led to a very disparate level in the quality of health provision around the coun­try. In January 1995, in a rare admission of problems, health officials privately reported that 500 government health posts were vacant.[39] The situation is particularly acute in ethnic minority areas. During 1995, for example, a third of the 150 positions for doctors in the Rakhine State were reportedly unfilled. Although it is technically difficult to resign from such posts, in ethnic minority areas many physicians from other areas either do not turn up for work or simply apply for transfer on their day of arrival rather than remain in what are widely regarded as hardship postings with few career prospects. Indeed, so serious are current shortages of doctors that in January 1995 the SLORC introduced regulations by decree, compelling all medical graduates to work in the state system for a minimum of three years before requests to resign or travel abroad will be considered. This, however, has not stopped the exodus.

Against this background, the second health sector in Burmathe private sector — is booming and provides an increasingly broad range of health care. Because of the lack of resources in the public sector, many people automatically turn to the private sector first, where many doctors have established reputations or moonlight from their state jobs. Indeed, many government doctors simply refer patients to their private clinics if they want speedy treatment — and if they are able to pay. In Burma's convulsive economy, the charges can be astro­nomical: in the private sector a hysterectomy operation can cost 30,000 kyats, for example, which is twice the official annual wages of most state workers. Nonetheless, the new class of rising rich in Burma, especially traders or those with access to foreign exchange, are able to afford such prices, as is evident from the recent fashion in certain business circles for expensive "poly-clinics" with private rooms and air-conditioning. With Burma promoting 1996 as its "Year of the Tour­ist", private physicians have similarly begun to target the health con­cerns of foreigners, and in October 1995 the first 24-hour international clinic was opened in Rangoon by the Singapore-based AEA medical centre chain.

 

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 Burma, the traditional or indigenous, which also works in the private market. There has long been a consensus that traditional practices, including homeopathic and Chinese herbal medicine, have a worthy place in the overall scheme of treatments available in Burma. The Health Ministry, for example, has a Department of Traditional Medicine[40], and over the years UNICEF has run training programmes to try and equip traditional birth attend­ants (known as lethe) with additional skills and knowledge, especially about hygiene and nutrition.

 

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 Burma, virtually anyone can set up as a private or independent health practitioner. As a result, across the country there are thousands of self-appointed medics masquerading as private medical experts, who give injections and every kind of fake or inappropriate treatment. By some estimates, they number at least one to each of Burma's 60,000 villages. On some occasions, such practi­tioners are preferred by local custom, but more often than not their main selling point is their quick availability and deceptive self-promotion when compared to public or properly-qualified private doctors.

 

The tragedy, as many hospitals in Burma have witnessed, is that patients suffering from emergency conditions, such as snake-bites or cerebral malaria, are often only brought in after life-saving time has already been wasted on such imposters by impoverished families who, in addition, have wasted their money. Many such practitioners have picked up titbits of health terminology during military service or during training as community health volunteers, and they are thus able to persuade their victims. In vast rural areas of Burma, however, there is no system of health information or reporting which would allow such very basic issues to be addressed. Moreover, even where deaths have occurred through obvious maltreatment, many physicians complain that there is no compulsion or incentive within the existing public health system to investigate such blatant health rights abuses, even though relevant mechanisms reportedly exist.

 

By contrast, the final health sector in Burma, that of the Burmese Armed Forces or Tatmadaw, has remained largely impervi­ous to the social upheavals of the past decade. Military hospitals are well-supplied with medicines and most have modern equipment. In addition to two large Defence Services hospitals in Rangoon, there are also military hospitals in Mandalay, Maymyo, Meiktila and other important regional towns, which in the last few years have been equipped with computerized blood-testing and other expensive ma­chinery. For many years, an estimated 50 newly-graduated doctors have been conscripted annually for a three-year period of service with the Tatmadaw, often in dangerous front-line areas. However, some doc­tors do also volunteer for appointments to military hospitals, since not only are working conditions more favourable but there are also greater career possibilities for research and specialism.

 

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 Defence Services Medical College in Rangoon, where many sons and daughters of military officers have gained admission. As a result, doctors in the public health system privately say that, just as in the former BSPP era, senior military officers are becoming ever more institutionalized and far removed from the daily health sufferings of most ordinary people.

 

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 Burma under successive governments since independence. Recognizing the worsening resource constraints within the existing system, a new "cost-sharing system" was announced for the country's 717 state-run hospitals[41], 1,424 rural health centres, 306 dispensaries and 353 maternal and child health centres to enable the public sector to raise income locally and compete more effectively with the burgeoning private market. "The community financing or community cost-sharing is just a precursor of health insurance and social security schemes of the United States and European countries," one senior health official claimed.[42]


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 Burma today. For such a reorientation to be effective, the peoples of Burma must themselves be mobilized to value the importance of health education after dec­ades of governmental failings and neglect. However, whether such essential reforms can be initiated during the present state of political deadlock and crisis is very far from certain


______________________________________________________________________

Chapter 4

HEALTH IN A SOCIETY UNDER CENSORSHIP


Burma today has one of the toughest systems of state censorship and media control of any country in the world. The damaging effects of years of censorship and health neglect in Burma are mani­fold and intrude into every health field. As will be discussed in this chapter, censorship is achieved by both direct means imposed by the authorities, and through the insidious — but equally debilitating — atmosphere of fear that permeates Burmese society and inhibits reporting and discussion of many issues relating to public health. In addition, there is such a paucity of information available on all aspects of public health and health care — and the information that there is often appears sketchy and potentially misleading — that it becomes impossible for informed public debate on policy to develop, and very difficult also for international agencies to plan and implement their humanitarian input in the most effective ways. There is an urgent need for freedom of research and for freedom to disseminate information in this field. Moreover, while certain public emergencies are sporadi­cally addressed through public information campaigns, many of the most common and life-threatening health risks that the Burmese peo­ples face are not realistically or publicly addressed by the government at all. In its failure to provide readily available information about such risks and how they can be avoided, the Burmese government has for many years demonstrated a negligence that threatens the health — and indeed the lives — of many of its people.


As
Burma slowly emerges from the 26-year era of General Ne Win's "Burmese Way to Socialism", a number of changes have occurred in the structure and appearance of the Burmese media, largely in response to economic change. Since 1988, an independent publish­ing industry that concentrates on business affairs has been allowed to develop, and various new journals occasionally comment on social or health issues. In the past eighteen months, for example, the popular magazines Thintbawa and Kyi-pwa-yay have both carried articles men­tioning AIDS, which were passed by the censors. Any criticism of the authorities or government policy, however, is strictly forbidden under a complex array of draconian censorship laws, and virtually all health education and reporting remains the sole prerogative of the government, which tightly controls all television, radio and daily newspapers.[43]


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 Burma, such reports — backed up by the copious use of statistics — can give the impression of an effec­tive system of country-wide response and co-ordination in health care. For example, when plague broke out in India during 1994, the SLORC responded with a high-profile national awareness campaign which was heavily promoted in the state media; guard duty was stepped up at all official entry points from India and attempts were made to control the local rat population.[46]

 

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 20 May 1995, for example, Dr Mya Than Nwe from the Medical Research Department spoke on state radio about health education after an outbreak of bacterial encephalitis in parts of the Magwe Divi­sion and Rakhine State.

                               

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 Burma's peoples. The problem is further exacerbated by the fact that it is very difficult for local health workers to travel and carry out research under current censorship and security laws, and virtually im­possible for them to publicize their findings independently, even when they become aware of serious and unrecognized health problems.

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 Burma, despite the obvi­ous spawning ground of local conditions, the health authorities were conspicuously late. By the time the SLORC woke up to the looming scale of the problem, hundreds of thousands of people may already have been infected (see Chapter 7).

 

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 Burma is often astonishing. Reproductive health, narcotics and HIV/AIDS stand out as areas where successive governments in Burma have failed to en­sure that the public is properly informed. The list, however, extends much further. For example, although malaria has long been a major cause of infant mortality, many villagers still believe that they can be infected by such means as eating bananas. The treatment of such global health hazards as tuberculosis, which is re-emerging in Burma, is similarly jeopardized by lack of information and the high drop out rate of sufferers before completing their treatment.[49] Equally striking, international agencies are discovering that attempts to rectify Burma's woefully inadequate sanitation and clean water systems through con­struction work have proven ineffective without the backup of commu­nity participation or health education. As UNICEF recently stated, "Lit­tle attention was given to the knowledge, attitudes and practices of beneficiaries."[50]

 

Another much neglected area of health care is the plight of Burma's large population of disabled people (save for military veter­ans), whose needs have been perennially under-funded and overlooked. For example, although it has been estimated that anywhere between 3.5 and 5 per cent of the population is blind or in other ways disabled, there are only six specialist schools in the country which can cater in total for a maximum of 400 children.[51] As a result, many parents simply keep blind or disabled children at home. The alternatives are bleak. As one physician remarked, "For many people, to become blind in Burma is virtually to become a beggar."

 

Of similar concern are the country's many leprosy sufferers. Burma is currently one of the world's six main country centres for leprosy, with over 40,000 registered patients in 1993. Some recent advances have been made in treatment, and an improved multi-drug therapy was introduced into Burma in 1992, once again demonstrating the impact that medical aid, when permitted, can bring. However, the broader health aspects are often neglected, and conditions in many of the "leper villages" vary widely. For example, there were widespread reports of considerable hardship and suffering during the forcible re­location (for reasons unknown to ARTICLE 19) of one leper community near Rangoon to an under-prepared site at Ngasu after the SLORC assumed power. None of these issues, however, is raised or substantively investigated in the state-controlled press.

 

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 Burma's health situation. Foreign journalists and aid workers, too, often face bureau­cratic delays or straight refusals in response to requests to visit certain areas or hospitals. Indeed, at some hospitals foreign visitors have been refused access to the wards; instead, they have to wait for patients to be brought for interview in separate rooms and in the presence of offi­cials. Despite the goodwill of foreign visitors, the authorities, it would appear, are extremely nervous about any negative comments or pub­licity.

However, perhaps the most contentious area of censorship and misreporting on health issues in Burma is in the publication of official statistics. The apparent readiness of the government to make cavalier use of social statistics was graphically illustrated to the world in 1987 when, in order to be accepted by the UN for Least Developed Country status, the previous national literacy rate of 78.6 per cent (for which Burma had twice won UNESCO prizes in the BSPP era) was dropped to just 18.7 percent.[52]

 

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 Burma: "With respect to health, it is hard to evaluate progress because of a lack of reliable data."[53] One of the most controversial statistics is the true figure for military spending as compared to expenditure on education and health. Opposition estimates of over 40 per cent of the national budget being swallowed up by military spending contrast with official government figures which, for many years, have stayed at around 20 per cent. There simply is no access to reliable data to assess such very different claims. But even on the basis of this lower figure, Professor Khin Maung Kyi, a Bur­mese economist at the National University of Singapore, has demon­strated that, using the criteria employed in the UNDP's Human Devel­opment Reports, Burma has the highest military spending as a percentage of government expenditure out of a comparable grouping of regional countries that includes Indonesia, Thailand, Bangladesh and Malaysia — and despite having no external enemies.[54] Equally stark, at around 152 per cent in 1992, Burma had by far the greatest imbalance of military expenditure against health and education spend­ing among these countries, with projections that it could rise to 200 per cent in 1996.[55]

Nonetheless, if many aspects of government and military spend­ing remain shrouded in mystery, there can be little doubt that increas­ing international scrutiny of Burma's social data in recent years has brought about a new sensitivity over the recycling of questionable information. This has been illustrated in the arguments of Dr Aung Tun Thet, a former Health Ministry official currently working with UNICEF. Dr Thet, for example, has argued that, although by most international political and economic indicators Burma is usually clas­sified with countries "in crisis", such as Afghanistan, Angola, Iraq, Mozambique, Sudan and Zaire, when various health and educational indicators are examined, Burma under the SLORC (or Nawatd) is ac­tually some way ahead in terms of general social progress.[56] Signifi­cantly, Dr Thet also asserts that, although in the past there had been "a tendency to hide the actual situation by producing dubious figures", since 1990 the SLORC has given "explicit directives to ensure the production of accurate social statistics".[57]

 

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 Burma's children and the fact that the majority of children do not complete primary school have been admitted on several occasions. Indeed, the provision of primary health care and universal access to basic education have been publicly heralded as main goals of Burma's National Programme of Action for the Sur­vival, Protection and Development of Myanmar's Children in the 1990s.

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 Burma, there are always wide regional and ethnic disparities which are not reflected in national figures. Sometimes, even national figures are changed quite dramatically. The most striking example is the much-quoted infant mortality rate (IMR), which is widely seen as a main indicator for national standards of health. In the early 1970s, the IMR was set by the Health Ministry at around 47 per 1,000 live births (for children under one), at which level it remained for twenty years, apparently unchallenged by UNICEF, the WHO and other international agencies, until 1992 when it was suddenly doubled by the Ministry of Health to 94 per 1,000 live births. At the same time, the official under-five mortality rate was similarly doubled to 147 per 1,000 live births, which is the fourth highest figure amongst the 14 countries in the UN's East Asia and Pacific Region.

 

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 Burma, especially in ethnic minority areas and the war zones.[61] Explained one foreign aid official, who asked to re­main anonymous:

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 Burma has been able to use its control over both health provi­sion and the media for its own political purposes. This is a trend which has accelerated under the SLORC. For example, after decades of neglect in most ethnic minority regions, the SLORC has been publicly offering the sudden prospect of hospitals, doctors, and access to foreign aid agencies and medical supplies in areas where the military authorities have an agenda for change; other minority areas, however, remain neglected. The one message constantly reinforced in the state media is that the military government is the only institution in the country which can provide such beneficial developments and which, by implication, should be the only conduit for international aid and funds. Opposition groups, on the other hand, believe that the provi­sion of aid solely through government channels is more likely to em­power the SLORC than the people it is intended to help. In achieving health solutions, all sectors — both governmental and non-govern­mental — must ultimately be expected to play a role. But, for the mo­ment, there remain vast areas of the country where international aid workers have no access to the community to judge the health realities or social infrastructures for themselves.

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 doc­
tors, 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 Kachin State, for example, quacks — who use unsteri-lized needles — claim to provide three years' protection against ma­laria by injection. What is actually in these injections has not been surveyed (some reportedly contain opium or heroin). But many of those who seek such backstreet treatments are heroin addicts, amongst whom alarmingly high rates of HIV-infection are now being detected (see Chapter 7).

 

Like many health issues in Burma, state restrictions and negli­gence mean that the scale of this problem has yet to be properly researched. It could be a local problem that is tied to the lifestyle and culture of intravenous drug users in north-east Burma. Some medical experts, however, are not so sure. They believe that many people may have already been unwittingly infected. "A time bomb" was the pri­vate verdict of one government doctor.

 

 

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 Burma.


In the parliamentary era of the 1950s, although there were many failings within the national health system, hospitals and physicians in
Burma enjoyed international renown. The door remained open to the international community, and many ethnic Indians continued to work as doctors in both the private and public sectors. Foreign diplomats and other patients, for example, would often travel from Thailand and other neighbouring countries for specialist treatment in Rangoon.

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 Burmese Way to Socialism. As political repression mounted, all industries were nationalized and most foreigners expelled, prompting a steady exodus of qualified doc­tors which has continued until today. Currently, several thousand doc­tors from Burma are believed to be working abroad.


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 Rangoon University in 1966 and the demotion of English to a minor subject in schools proved a serious handicap to medical students. With funds always scarce, translations of scientific texts never kept pace with demand, and the publication of essential training materials was further delayed by bureaucracy and censorship.

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 United States' Embassy on 19 September, the day after the SLORC assumed power. Eyewitnesses said that, elsewhere in the city, nurses and medical personnel, including one carrying a Red Cross flag, were shot at by the security forces when they went to try and help some of the wounded.[64] In the aftermath of these shootings, a number of well-known doctors and medical students joined the several thousand democracy activists who fled into territory controlled by armed ethnic opposition groups following the SLORC's assumption of power. Prominent among them were Dr Naing Aung and Dr Thaung Htun, both leading figures in the All Burma Students Democratic Front (ABSDF), which is still militarily active and runs health programmes of its own in a few bor­der regions today.

 

In government-controlled areas, meanwhile, the political pressures on medical practitioners have been relentless. Like all uni­versities and colleges of higher education, Burma's four main insti­tutes of medicine were periodically closed by the authorities for much of 1988-1991. Even though medical classes resumed before other faculties, another massive backlog in the training and qualification of health personnel was caused. By early 1991, huge staffing gaps were appearing in many of the country's hospitals and clinics. Then, in another intensification of pressure on public servants, in April 1991 all doctors employed in the public sector — like other civil servants - were barred from engaging in politics under SLORC decree No. 1/91 and required to fill in forms answering 33 detailed questions on their political views, including about the Tatmadaw, insurgent groups, the NLD leader Aung San Suu Kyi, the US Central Intelli­gence Agency and the British Broadcasting Corporation (BBC). Sub­sequently, hundreds more medical personnel were reported to have been sacked on the basis of their answers, bringing to 15,000 the number of civil servants that Lieutenant-General Khin Nyunt announced had been sacked or disciplined since the SLORC came to power.[65]

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 30 April 1991, for exam­ple, two respected physicians, Dr Zaw Myint Maung, the elected Member of Parliament (MP) for Amarapura-1, and Dr Zaw Myint, MP-elect for Henzada-2, were both sentenced to 25 years' imprison­ment on imprecise sedition charges for allegedly planning to "set up an illegal government".[67] In March 1996, Dr Zaw Myint also received an additional 12 year sentence under the Penal Code and section 5(j) of the Emergency Provisions Act as part of a group of 21 political prisoners in Insein jail who were convicted of offences likely to "disrupt" the morality, security or stability of the country. The evi­dence offered against them was the possession of alleged anti-govern­ment materials, including a letter describing poor health conditions in the prison, which had been smuggled out to the UN Special Rapporteur to Myanmar (see Chapter 6.3).

 

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 Myanmar, Dr Aung Khin Sint was unexpectedly released in February 1995, but Dr Ma Thida, who has reportedly suffered from tuberculosis, remains in prison amid growing concerns about her health (see Chapter 6.3).

 

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 China in 1992. Subsequently, he embarked on a postgraduate degree programme at the University of Singapore and continued his contact with international health officials. Briefly back in Burma, he was arrested at Mingaladon Airport on 4 July 1994 and later sentenced to 15 years' imprisonment for allegedly "spreading false news" and other offences. In a broad array of charges, he was convicted under the 1950 Emergency Provisions Act (5e), Section 17/1 of the Unlawful Associations Act and Section 5 of the 1923 Official Secrets Act as well as on various currency and customs charges. Col­leagues, however, believe that the latter charges were merely intended as an attempt to discredit him. The real reason for his arrest, they say, was his academic research into Burmese politics and his well-known contacts with foreigners, including the UN's Special Rapporteur to Myanmar to whom the New Light of Myanmar alleged he had helped send "fabricated news" in 1992.[69]

 

Khin Zaw Win's only "offence", it thus appears, was that he had tried to speak out. In a conference paper distributed in Australia, he had written in poignant terms of the consequences of political deadlock and the need for peaceful reform:

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 Burma's Writers Association and a central committee member of the NLD, was arrested on trumped up charges of being involved in an illegal abortion. His link to the case was tenuous; a young man whose partner had recently undergone an abor­tion briefly stayed at his house. Nevertheless, in October 1989 he and another NLD colleague, U Ngwe Hlaing, were sentenced under section 216 of the Penal Code to three years' hard labour for allegedly "harbouring an offender".[71] Abortion is illegal in Burma, but prosecu­tions are rarely brought. However, while the young couple and doctor who carried out the abortion have since been released, Win Tin was kept in jail after reportedly receiving a further 11 year sentence under the 1950 Emergency Provisions Act for reasons that have never been publicly disclosed. In March 1996, Win Tin also received an addi­tional five year sentence along with Dr Zaw Myint and 19 other prisoners who had been accused of anti-government activities in jail, including writing to the UN Special Rapporteur to Myanmar (see Chap­ter 6.3). Now 65 years old, Win Tin is in poor health after over six years without adequate medical treatment and is suffering from chronic spondylitis, for which he has to wear a neck brace.


Finally, in addition to the repression suffered by individual doc­
tors 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 Burma, which are increasingly being required, in response to international concern, to try to work with independent and representative NGOs in the commu­nity. Yet, it is these very government-backed NGOs, as well as the Health Ministry and local township authorities, which the SLORC has been urging international organizations to accept as local partners.


After years of political repression and malaise, the question of
indigenous NGOs in Burma is a difficult one. In fact, independent NGOs of the kind envisaged by international agencies have never become fully established. For a variety of political and cultural reasons, despite the traditional generosity of the Burmese peoples towards community projects, indigenous NGOs dealing with local or specialist issues (such as disabilities, drug addiction or ethnic nation­ality questions) have either been prohibited or never properly developed — and this has long applied in armed opposition territory as well as in government-controlled areas.


Founded in 1949,
Burma's oldest NGO, the Myanmar Medical Association (MMA), began life as a professional association and currently has over 6,000 members, with 50 branches at the township or state/divisional levels. Consisting of physicians from both the pub­lic and private sectors, the MMA was pulled into the government's orbit during the time of the BSPP when senior officials in the Ministry of Health took up key leadership posts in its governing hierarchy. How­ever, although the MMA continues to publish its own journal and run occasional workshops and programmes (including an AIDS preven­tion project with World Vision in Kawthaung), many health workers feel that the MMA has yet to re-establish its independence under the present SLORC government.


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 Thailand and more recently, in 1994-1995, in the repatriation of over 190,000 Muslim refugees from Bangladesh, when victims of human rights abuses were allegedly sent back against their will to Burma (see Chapter 6.2). Indeed, opposition groups allege that Military Intelligence officers and informers are routinely placed within the MRC's ranks, causing many communities — especially ethnic minorities — to view the MRC as another branch of government.


Likewise, even the treatment of children is not free from politi­
cal 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 Burma. Experience the world over has demonstrated that the existence of such popular and democratic institutions is fundamental to the building of civil society and integral to sustainable development and political reform.


In response to such concerns by donor governments, in 1992
the UNDP's Governing Council decided to reorientate its programmes in Burma towards the grass roots level.[72] Since this time, as the door to Burma slowly opens, a number of foreign NGOs and UN agencies have been urging the Burmese health authorities to accept that effective health care is based upon genuine participation by local communities. This important ideal, however, would appear contradicted by events inside Burma. For not only has the SLORC continued to reject the democratic aspirations of the Burmese peoples, as expressed in the result of the 1990 general election, but any members of society, who are suspected of anti-government opinions, face discrimination in gaining public positions or forming or joining local organizations of their choice. In many townships, for example, NLD supporters have been barred from school parents' and teachers' associations. Opposi­tion groups thus claim that the provision of all aid is still politically dominated by the SLORC-led government.


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 Burma are to be allowed to take control of their own health destinies. Many community groups and leaders are willing to accept this important task. In addition to opposition political groups, many community or religious-based groups — including Buddhist, Christian and Muslim organizations — are keen to expand the scope of their activities to help meet the needs of their communities. Over the years, for example, several Christian-based groups have been per­mitted to undertake educational projects in fields as diverse as AIDS awareness to running kindergarten classes. In addition to the Christian churches, Muslim or Buddhist organizations, such as the Young Men's Buddhist Association, also run orphanages, and in some areas Buddhist monks, who were once the country's main suppliers of tradi­tional medicine, have recently begun to expand their role in working with local drug addicts or AIDS-sufferers. Under existing legislation, however, religious organizations are barred from straying outside a strictly religious mandate. Existing programmes remain technically under evangelical auspices: and one of the reasons why the former BSPP government moved to purge the Buddhist Sangha in the late 1970s was to prevent the country's estimated 150,000 monks from playing such a social role, which was deemed to bring them into possible opposition or competition with the authorities. Indeed, politi­cal pressures on Buddhist organizations, in particular, have intensified under the SLORC.[75] Furthermore, despite the obvious popularity of such religious-based organizations within their communities, the SLORC still appears undecided if it will allow any of these groups — whether Buddhist, Christian or Muslim — to become local partners to international aid organizations in any large-scale or significant way.[76]


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 Burma that had been democrati­cally shown to represent the will of the people. The party welcomed, NLD leaders said, the creation and work of indigenous NGOs in the community. In this way, by following the primary objectives of the UNDP's Human Development Initiative[77], the NLD considered that humanitarian and development aid could be more ethically targeted by democracy supporters at the poorest and most disadvantaged mem­bers of society.

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 Myanmar, Mr. Giorgio Giacomelli was treated well. But under the arrangement of the UNDP Resident Representative, he stealthily met the wife of the man with the long nose at the UNDP office in the afternoon of 11 February 96. He did so in disregard of the hospitality extended to him, without paying attention to his dignity and not in concert with his job. He then had clandestine dis­cussions not in favour of drug control measures taken in Myanmar.[78]

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 Burma. In contrast to the work of the NLD and other indigenous groups in the community, many doctors in Burma believe that the next organization to receive the same preferential treatment as the MRC and MMCWA will be the government-backed Union Solidarity and Development Association (USDA), a mass organiza­tion formed in late 1993 after the SLORC's earlier attempt to form a successor party to the BSPP failed to gain popular support. With an estimated two million members, the USDA is now organized by the authorities throughout most SLORC-controlled areas of the country and frequently mobilized, in mass rallies, to demonstrate community backing for all the government's plans. Despite its quasi-political status, in early 1996 the USDA was included in a list of "national NGOs" approved by the Health Ministry.[79] Indeed, international health workers report that USDA representatives already sit in, as a matter of course, on planning meetings and health seminars in many townships. In Sittwe, for example, the Rakhine State capital, the MMCWA is even located in the USDA building.


 

 

Chapter 6

CONFLICT AND HUMANITARIAN CRISIS


Burma today is confronted by a host of complex humanitarian issues related to both health and human rights. Many are long­standing problems dating back to Burma's independence in 1948. How­ever, for present-day purposes, they largely fall into three broad cat­egories: death and other physical sufferings resulting from the conduct of war; refugee protection and the internal displacement of civilians; and, finally, the welfare and treatment of prisoners and detainees. All these issues have grave health implications, and have long been veiled under a cloak of censorship which has precluded the development of desperately needed solutions.

6.1   The Backdrop Of War

Undoubtedly the most neglected area of health care in Burma is the humanitarian crisis that exists in many rural areas as a result of over four decades of armed conflict. Virtually all areas of the country have been affected at some stage. There are communities in the Delta and Pegu Yoma regions of Lower Burma, for example, that still suffer from impoverishment and malnutrition as a result of displacement during fighting over 20 years ago. Since the late 1970s, however, the crisis has been most deeply felt in Burma's ethnic minority borderlands, where the human and economic cost of war has been devastating. Ethnic minority peoples constitute an estimated third of the 46 million population and, even today, there are over 20 different ethnic national­ist forces still under arms — both with or without cease-fires with the government.

 

Until 1988, civilian casualties and the state of civil war in Burma were scarcely mentioned in the state-controlled press. When armed opposition groups were referred to, they were usually described as "bandits", "opium smugglers" or "racist saboteurs". The one excep­tion was on Armed Forces Day in March ach year when the government would usually acknowledge the deaths of several hun­dred troops in the preceding twelve months as opposed to an average 2,500 "insurgents". Opposition forces, by contrast, have estimated the death rate — including civilian victims — at around 10,000 each year, with large annual fluctuations depending on the intensity of the fight­ing.[80] Certainly, the documented casualty rates among several ethnic minority groups have been appalling. In north-east Burma, for exam­ple, the Kachin Independence Organization recorded the deaths of 33,336 civilians in the years 1961-1986 alone, while an unpublished UN survey undertaken in 1991 in Tachilek district in the Shan State revealed a ratio of 1,430 females to 1,000 males, indicating a high mortality rate for ethnic minority men in the fighting.[81]

 

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 Burma. Neutral observers, including the International Committee of the Red Cross, were strictly barred from the war zones, and no reference was ever made to such important international protocols as the 1949 Geneva Conventions on the Protection of the Victims of War, which set universal minimum standards of humanitarian protection during times of war.[82]

 

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 Asia's least reported conflicts has begun to dissipate. In part, this has been in response to the upsurge in international media interest that followed the events of 1988, when an estimated 10,000 students and other democracy activists fled from Rangoon and other urban areas into territory controlled by armed ethnic minority forces after the SLORC took power. Fierce battles were frequently witnessed by foreign journalists along the Thai and Chinese borders between 1988 and 1992. At the same time, as growing numbers of refugees fled the fighting, serious international concern was also raised over the plight of the civilian victims of the war by organizations such as Amnesty International and Asia Watch (now Human Rights Watch/Asia).[85]

 

However, changing international awareness of the scale of Burma's humanitarian disaster can also be attributed to an important shift in government policy under the SLORC. This followed the unex­pected collapse, due to ethnic mutinies, of the country's largest insur­gent force, the Communist Party of Burma, in 1989. The first evi­dence of this change came in January 1990 when General Saw Maung, the former SLORC Chairman, publicly admitted that the real death toll in over 40 years of armed conflict "would reach as high as mil­lions".[86] Since this landmark statement, the SLORC has offered peace talks — with the added enticement of development aid — to all of Burma's armed opposition ethnic forces for the first time since 1963.

 

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 Rangoon.[87] Similarly, the cornerstone of the SLORC's new ethnic policy is the Border Areas Development Programme (BADP), which techni­cally co-ordinates projects between the Health Ministry and other gov­ernment departments, but remains under direct military control. This has led to some very different claims over what is actually being achieved. For example, since the BADP's establishment in 1989, the SLORC claims to have invested over US$ 400 million (2,842 million kyats [88]) on development initiatives in ethnic minority regions, while opposition groups claim that most of this expenditure has been on buildings and roads, with precious little being spent on health projects where there is local participation in decision-making. Moreover, the SLORC continues to try and restrict all contacts between international aid agencies and ethnic minority forces, which actually control many of these lands (see Chapter 5).

 

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 Burma, with over 50,000 troops under arms, have cease-fires with the SLORC.[89] Of equal importance, the SLORC finally acceded to the Geneva Conventions on the Protection of the Victims of War in 1992. Previously, Burma was one of just four coun­tries not to have signed.

 

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 21 March 1995, for example, a cease-fire was signed by the Karenni National Progressive Party (KNPP) in Loikaw, the Kayah State capital, in which the SLORC reportedly agreed to stop using local civilians for forced labour or pottering. However, just three months later, seven badly wounded por­ters were rushed by local medics to hospital in neighbouring Thailand after being ordered to walk ahead of government troops through a KNPP minefield. As local clashes over trade and territory escalated, few observers were surprised when full-scale fighting broke out again in January 1996. Similarly, in May 1996 there were reports of a number of villagers being shot dead and many villages destroyed after the SLORC ordered the forced relocation into government-held areas of over 300 villages in the central and southern Shan State, in an attempt to take advantage of the military vacuum caused by the MTA cease­fire and the apparent defection of the MTA leader, Khun Sa, to Ran­goon.

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 Myanmar presented evidence to the UN General Assembly of "tortur