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Human rights abuses threaten health in Burma
World Report
Human rights abuses threaten health in Burma Decades of neglect, civil war, and corruption have rendered Burma’s health system incapable of responding to infectious diseases and other health risks. And, as the country closes its doors to more and more aid agencies, the situation only looks set to worsen. Rhona MacDonald reports.
www.thelancet.com Vol 370 August 4, 2007
the situation. “Since 2005, the government of Myanmar has imposed increasingly severe restrictions on ICRC activities, making it impossible for the organisation to continue visits to thousands of detainees in line with its usual working procedures, which include carrying out private interviews with detainees. This has also prevented the ICRC from conducting independent field visits to conflict affected areas and from delivering aid to civilians according to strictly humanitarian, neutral, and apolitical criteria”. Haddad added that “the ICRC’s activities have therefore been drastically scaled down to a few limited projects in the field of physical rehabilitation for amputees and mine victims”. The military government, which has ruled the country since 1962, has severely restricted the movement of international aid agencies and nongovernmental organisations (NGOs) with the result that some have had to leave the country despite its many health problems. Almost 90% of Burma’s 52 million population are at risk of malaria, and the country has one of the highest
rates of tuberculosis in the world with nearly 97 000 cases detected every year. There are 25 000 estimated new infections of HIV every year, with significant spreading of the disease in young people and highrisk groups. A third of children are chronically malnourished, 15% of the population is food insecure, and the under-5 mortality rate is 106 per 1000 compared with 21 per 1000 in neighbouring Thailand. Yet the military government spends less than US$1 per person on health and education every year—national expenditures in health and education are 3% and 10%, respectively. The military, including an army of over 450 000 soldiers, receives 40% of the budget, even though Burma has been at peace with its neighbouring countries for decades. According to a recent report by researchers from the Human Rights Center of the University of California at Berkeley and Johns Hopkins Bloomberg School of Public Health, the Burmese military is destroying medical supplies intended for civilian populations and detaining and killing
See Series page 449
The printed journal includes an image merely for illustration Panos Pictures
At the end of June, the International Committee of the Red Cross (ICRC)—in a rare departure from its usually confidential stance—publicly denounced the repeated violations of international humanitarian law committed against civilians and detainees by the military government in Burma (Myanmar). The use of detainees as porters for the armed forces and many acts of violence committed against civilians living in conflict affected areas along the Thai-Burma border, are among the long list of abuses committed by the government. In a press statement on June 29, Jakob Kellenberger, the president of the ICRC said “The ICRC has repeatedly drawn attention to these abuses but the authorities have failed to put a stop to them...The continuing deadlock with the authorities has led the ICRC to take the exceptional step of making its concerns public”. Between 1999 and 2005, the ICRC visited hundreds of detainees in more than 70 prisons and labour camps to assess their living conditions and treatment. On the basis of the ICRC’s recommendations, and with its support, the detaining authorities worked to improve the water supply, accommodation, and provision of health care available to detainees. This development led to measurable progress: by 2005, the mortality rate of detainees had dropped by 50%, even though it still remained twice as high as within the general population. But, since late 2005, the ICRC has not been able to visit any places of detention and the humanitarian situation seems to be deteriorating. Carla Haddad, spokesperson for the ICRC at its headquarters in Geneva, told The Lancet more about
A Karen refugee distributes rice rations to children in a hill camp near the Thai-Burma border
375
World Report
Panos Pictures
The printed journal includes an image merely for illustration The military government has ruled Burma by force for over 40 years
medical workers in areas of internal conflict. These abuses have left the population vulnerable to death and illness from malnutrition, malaria, tuberculosis, night blindness due to vitamin A deficiency, and diarrhoeal diseases. The report—which is based on data on infectious diseases gathered from health clinics and interviews with health professionals, governmental officials, and non-governmental and community-based organisations—also states that decades of neglect, civil war, and corruption have rendered the country’s health system incapable of responding to these endemic infectious diseases and that even with substantial amounts of foreign aid Burma’s capacity to curb these diseases is hindered by its military leaders. Eric Stover, the lead author of the report, says that “there has to be a regional response to Burma’s chronic crisis. Health professionals and local NGOs should be trained to standardise their collection and analysis of infectious disease data. This will facilitate a coordinated response to both chronic and emerging infectious diseases such as avian influenza”. He added that “donors should support such a regional effort”. However, a recent report from the UK House of Commons International Development Committee emphasised that donors are not giving enough and that increased aid is desperately 376
needed to help displaced people hiding in the jungles and conflict zones of Burma, many of whom have infectious diseases. The UK’s Department for International Development—as one of only four donors based in Burma— is in a leading position to scale up the assistance given to displaced people and refugees. Shahid Malik, the UK Minister for International Development told The Lancet “The British Government is committed to addressing the dreadful levels of poverty in Burma, which is why the UK has been playing a leading role in establishing programmes to provide health services in the country”. The UK, Australia, the European Commission, the Netherlands, Norway, and Sweden have set up the Three Diseases Fund (known as the 3D Fund), to help fight tuberculosis, malaria, and HIV/AIDS in Burma as part of a $100 million joint-donor programme set up in response to the Global Fund to fight AIDS, Tuberculosis and Malaria having to pull out of Burma in 2005 due to the restrictions imposed by the Burmese Government. The aim of the 3D Fund is to target those most at risk of being infected by each of the three diseases, with a particular focus on those who have little or no access to public-health services. Although the authors of the joint University of California, Berkeley, and Johns Hopkins report acknowledge that large infusions of foreign aid directed at the health sector can potentially lessen the burden of infectious diseases in Burma, they also caution that it could have unintended consequences. “This is tricky terrain”, said Stover. “There is always the danger that foreign aid aimed at one specific disease can divert health professionals and their institutions from addressing other serious health problems, and can also provide national authorities with a ready excuse for decreasing even further their paltry expenditures in health.”
Stover and his team are now planning to map what all the various organisations are doing in Burma and its borders and then hold subregional training seminars. “There is no time to wait for international agencies to do something. We need to act now”, he said. Stover also believes in a soft and hard approach. “International humanitarian aid needs to reach those most in need, but there also has to be continued pressure on the Burmese Government to increase its spending on health, lift the travel restrictions it has imposed on aid and development organisations, and increase the amount of cross border assistance to internally displaced people”, he said. Stover thinks that it is vital to get China on board for progress to be made, especially now that some Chinese health professionals are concerned with the rates of infectious diseases at the Chinese border with Burma. In his press statement, the ICRC’s president reminded all states party to the Geneva Conventions of their obligation, under article 1, to respect and ensure respect of the Conventions. Haddad explains what this should mean in practice: “In their bilateral talks with the government of Myanmar, states should urge the government of Myanmar to respect international humanitarian law”. Meanwhile the continuing behaviour and actions of the armed forces are contributing to a climate of constant fear in the population and have forced many people to leave their homes and join the ranks of the internally displaced, or flee abroad. And, according to the Reuters news agency, Thailand has now closed its doors to new refugees, making their future increasingly uncertain. As Haddad says, the ICRC “are concerned about the lack of provision of basic services to civilians living along the Thai-Myanmar border where no humanitarian organisation has access today”.
Rhona MacDonald www.thelancet.com Vol 370 August 4, 2007
Human rights abuses threaten health in Burma Decades of neglect, civil war, and corruption have rendered Burma’s health system incapable of responding to infectious diseases and other health risks. And, as the country closes its doors to more and more aid agencies, the situation only looks set to worsen. Rhona MacDonald reports.
www.thelancet.com Vol 370 August 4, 2007
the situation. “Since 2005, the government of Myanmar has imposed increasingly severe restrictions on ICRC activities, making it impossible for the organisation to continue visits to thousands of detainees in line with its usual working procedures, which include carrying out private interviews with detainees. This has also prevented the ICRC from conducting independent field visits to conflict affected areas and from delivering aid to civilians according to strictly humanitarian, neutral, and apolitical criteria”. Haddad added that “the ICRC’s activities have therefore been drastically scaled down to a few limited projects in the field of physical rehabilitation for amputees and mine victims”. The military government, which has ruled the country since 1962, has severely restricted the movement of international aid agencies and nongovernmental organisations (NGOs) with the result that some have had to leave the country despite its many health problems. Almost 90% of Burma’s 52 million population are at risk of malaria, and the country has one of the highest
rates of tuberculosis in the world with nearly 97 000 cases detected every year. There are 25 000 estimated new infections of HIV every year, with significant spreading of the disease in young people and highrisk groups. A third of children are chronically malnourished, 15% of the population is food insecure, and the under-5 mortality rate is 106 per 1000 compared with 21 per 1000 in neighbouring Thailand. Yet the military government spends less than US$1 per person on health and education every year—national expenditures in health and education are 3% and 10%, respectively. The military, including an army of over 450 000 soldiers, receives 40% of the budget, even though Burma has been at peace with its neighbouring countries for decades. According to a recent report by researchers from the Human Rights Center of the University of California at Berkeley and Johns Hopkins Bloomberg School of Public Health, the Burmese military is destroying medical supplies intended for civilian populations and detaining and killing
See Series page 449
The printed journal includes an image merely for illustration Panos Pictures
At the end of June, the International Committee of the Red Cross (ICRC)—in a rare departure from its usually confidential stance—publicly denounced the repeated violations of international humanitarian law committed against civilians and detainees by the military government in Burma (Myanmar). The use of detainees as porters for the armed forces and many acts of violence committed against civilians living in conflict affected areas along the Thai-Burma border, are among the long list of abuses committed by the government. In a press statement on June 29, Jakob Kellenberger, the president of the ICRC said “The ICRC has repeatedly drawn attention to these abuses but the authorities have failed to put a stop to them...The continuing deadlock with the authorities has led the ICRC to take the exceptional step of making its concerns public”. Between 1999 and 2005, the ICRC visited hundreds of detainees in more than 70 prisons and labour camps to assess their living conditions and treatment. On the basis of the ICRC’s recommendations, and with its support, the detaining authorities worked to improve the water supply, accommodation, and provision of health care available to detainees. This development led to measurable progress: by 2005, the mortality rate of detainees had dropped by 50%, even though it still remained twice as high as within the general population. But, since late 2005, the ICRC has not been able to visit any places of detention and the humanitarian situation seems to be deteriorating. Carla Haddad, spokesperson for the ICRC at its headquarters in Geneva, told The Lancet more about
A Karen refugee distributes rice rations to children in a hill camp near the Thai-Burma border
375
World Report
Panos Pictures
The printed journal includes an image merely for illustration The military government has ruled Burma by force for over 40 years
medical workers in areas of internal conflict. These abuses have left the population vulnerable to death and illness from malnutrition, malaria, tuberculosis, night blindness due to vitamin A deficiency, and diarrhoeal diseases. The report—which is based on data on infectious diseases gathered from health clinics and interviews with health professionals, governmental officials, and non-governmental and community-based organisations—also states that decades of neglect, civil war, and corruption have rendered the country’s health system incapable of responding to these endemic infectious diseases and that even with substantial amounts of foreign aid Burma’s capacity to curb these diseases is hindered by its military leaders. Eric Stover, the lead author of the report, says that “there has to be a regional response to Burma’s chronic crisis. Health professionals and local NGOs should be trained to standardise their collection and analysis of infectious disease data. This will facilitate a coordinated response to both chronic and emerging infectious diseases such as avian influenza”. He added that “donors should support such a regional effort”. However, a recent report from the UK House of Commons International Development Committee emphasised that donors are not giving enough and that increased aid is desperately 376
needed to help displaced people hiding in the jungles and conflict zones of Burma, many of whom have infectious diseases. The UK’s Department for International Development—as one of only four donors based in Burma— is in a leading position to scale up the assistance given to displaced people and refugees. Shahid Malik, the UK Minister for International Development told The Lancet “The British Government is committed to addressing the dreadful levels of poverty in Burma, which is why the UK has been playing a leading role in establishing programmes to provide health services in the country”. The UK, Australia, the European Commission, the Netherlands, Norway, and Sweden have set up the Three Diseases Fund (known as the 3D Fund), to help fight tuberculosis, malaria, and HIV/AIDS in Burma as part of a $100 million joint-donor programme set up in response to the Global Fund to fight AIDS, Tuberculosis and Malaria having to pull out of Burma in 2005 due to the restrictions imposed by the Burmese Government. The aim of the 3D Fund is to target those most at risk of being infected by each of the three diseases, with a particular focus on those who have little or no access to public-health services. Although the authors of the joint University of California, Berkeley, and Johns Hopkins report acknowledge that large infusions of foreign aid directed at the health sector can potentially lessen the burden of infectious diseases in Burma, they also caution that it could have unintended consequences. “This is tricky terrain”, said Stover. “There is always the danger that foreign aid aimed at one specific disease can divert health professionals and their institutions from addressing other serious health problems, and can also provide national authorities with a ready excuse for decreasing even further their paltry expenditures in health.”
Stover and his team are now planning to map what all the various organisations are doing in Burma and its borders and then hold subregional training seminars. “There is no time to wait for international agencies to do something. We need to act now”, he said. Stover also believes in a soft and hard approach. “International humanitarian aid needs to reach those most in need, but there also has to be continued pressure on the Burmese Government to increase its spending on health, lift the travel restrictions it has imposed on aid and development organisations, and increase the amount of cross border assistance to internally displaced people”, he said. Stover thinks that it is vital to get China on board for progress to be made, especially now that some Chinese health professionals are concerned with the rates of infectious diseases at the Chinese border with Burma. In his press statement, the ICRC’s president reminded all states party to the Geneva Conventions of their obligation, under article 1, to respect and ensure respect of the Conventions. Haddad explains what this should mean in practice: “In their bilateral talks with the government of Myanmar, states should urge the government of Myanmar to respect international humanitarian law”. Meanwhile the continuing behaviour and actions of the armed forces are contributing to a climate of constant fear in the population and have forced many people to leave their homes and join the ranks of the internally displaced, or flee abroad. And, according to the Reuters news agency, Thailand has now closed its doors to new refugees, making their future increasingly uncertain. As Haddad says, the ICRC “are concerned about the lack of provision of basic services to civilians living along the Thai-Myanmar border where no humanitarian organisation has access today”.
Rhona MacDonald www.thelancet.com Vol 370 August 4, 2007