OPINION | Denial of humanitarian assistance is a death sentence in Myanmar
What we are seeing now is worse than any other period of violence in the state since 2017.
Since the day conflict resumed in Myanmar’s Rakhine state on 13 November 2023, a continued disruption of basic services and blockage of supply routes has led to severe challenges for people in accessing necessities such as food, essential healthcare, and a safe place to shelter.
What we are seeing now, as expressed by some of our staff, is worse than any other period of violence in the state since 2017, when hundreds of thousands of people from Myanmar’s minority Muslim Rohingya community were forced to flee to Bangladesh.
Conflict has resulted in the destruction of infrastructure, including homes, schools, and healthcare facilities, exacerbating the humanitarian crisis. Fuel, electricity, and phone connection are scarce, isolating people and reducing their ability to seek help.
While this is affecting all communities in Rakhine, we are concerned about the escalating ethnic dynamics and divisive language being used, with armed groups pushing Rohingya men to fight alongside them and forcing Rohingya communities to protest against the opposing side.
Yet, in the face of this crisis, humanitarian organisations are left powerless to respond.
Unable to deliver healthcare
MSF has been in Rakhine state since 1994 providing medical assistance for people with diseases like malaria, HIV/TB, diabetes, hypertension, care for children under-five, and care for pregnant and breastfeeding women. Every time the stability of the state has wavered, our medical programmes are constrained and people’s access to healthcare has suffered.
Humanitarian access in the state has been heavily controlled through administrative procedures. All humanitarian organisations depend on travel authorisations to run their activities, and when conflict ignites, travel restrictions hinder humanitarian activities, rendering it difficult to provide lifesaving services.
Emergency referrals are at times life-saving for patients, particularly for Rohingya people who face severe restrictions imposed on all aspects of their lives.
With the resumption of the latest conflict in November 2023, travel authorisations were revoked and most of our clinics were forced to close. Six months on, none of the 25 mobile clinics MSF was running in Rakhine are operational. As a consequence, MSF’s outpatient consultations have significantly dropped from 6,696 in September 2023 to 236 in April 2024.
We have seen a drastic reduction in the numbers of emergency referrals we are able to support in Rakhine state. MSF teams referred 264 patients in need of emergency care to hospitals in October 2023, but this number decreased to only 28 patients in March 2024 because of lack of authorisation to run services and because of lack of functioning hospitals to refer patients to.
These emergency referrals are at times life-saving for patients, particularly for Rohingya people who face severe restrictions imposed on all aspects of their lives, including their freedom of movement, making travelling to access available secondary healthcare a huge challenge.
Scarcity of medical supplies
Not only are people blocked from reaching the remaining health facilities, essential drugs can’t reach them either. Both the transportation of people and of supplies is extremely challenging within Rakhine (between townships under control of different armed groups) and from outside the state (Yangon to Sittwe), leading to scarcity in essential medication, including antibiotics and drugs for HIV, pregnancies, non-communicable diseases, mental healthcare and injuries.
Any medical supplies between townships that could be used for care of wounded soldiers are banned. This includes sanitary pads and diapers, as these could hypothetically be used to apply pressure to a wound to stop the bleeding.
Decimation of available healthcare
Lack of authorisation notwithstanding, the increasing intensity of the violence, with airstrikes and armed clashes leading to heightened insecurity, has also made the functioning of humanitarian organisations almost impossible.
The conflict affected MSF’s structures as well – a shell landed in the Mrauk-U office compound in the beginning of 2024, and the MSF’s office and pharmacy in Buthidaung was burnt down on 15 April – leading to a decimation of available healthcare options for people in Rakhine state.
The availability of public healthcare has reduced rapidly. Healthcare structures have been damaged by artillery, airstrikes, or caught in the centre of active conflict, forcing staff to leave hospitals and health centres. In central Rakhine, Mrauk-U and Pauktaw hospitals are no longer functioning, and Min Bya hospital was already damaged by artillery at the end of last year. In northern Rakhine, the township hospitals of Maungdaw and Buthidaung are not functioning, leaving people with no secondary healthcare options.
The way the dynamics of the conflict have played out over the last six months has significantly impacted every aspect of daily life for communities in Rakhine and hugely increased the demand for humanitarian assistance.
In Pauktaw, where MSF ran clinics for both Rohingya people living in displacement camps and Rakhine communities, the disruption of MSF activities have had serious consequences. People in these areas no longer have access to healthcare, as MSF’s clinics are closed and access routes – mostly by water - are heavily controlled by checkpoints. Pregnant women in Pauktaw can no longer access Sittwe General Hospital, including for emergency care. As a consequence, at least one Rohingya woman and her baby died after they were denied access to Sittwe. Two other patients who were on their way back after receiving care drowned in the sea, as people are forced to find alternative ways to travel – if they can travel at all.
Between November 2023 and March 2024, MSF teams have recorded nine maternal deaths or stillbirth cases, likely a fraction of the deaths arising due to lack of available healthcare.
Disease outbreaks will go unattended
The end of the dry season is also approaching fast. Usually, water scarcity leads to an increase in cases of acute watery diarrhoea (AWD) and skin diseases. Every year, MSF and other organisations aim to respond to both prevent and treat these diseases, but in many townships in Rakhine this is currently impossible.
In many other townships, it is challenging for humanitarian and health organisations to have any visibility on outbreaks and illness at all.
Last November, there were more than 100 cases of AWD in Maungdaw. MSF, in collaboration with the local health authority, supported 80 emergency referrals of patients in need of hospitalisation from this cohort. This year, these emergency services are not available, and MSF is already seeing the dire consequences.
In Aung Mingalar in Sittwe, where 98 cases of AWD were reported in children under-five and pregnant women alone in April and May this year, two patients passed away. In that same period, 222 cases were reported in just one Rohingya IDP camp in Pauktaw, of which 201 were in one week, and 7 children died. In many other townships, it is challenging for humanitarian and health organisations to have any visibility on outbreaks and illness at all, as the access restrictions and challenges make it impossible to carry out assessments.
Nowhere to go
Now, all communities across the entire state are confronted with movement restrictions and challenges in accessing healthcare that Rohingya people have endured for years. Rohingya people were stripped of their citizenship at home in Myanmar in 1982, denying them their fundamental rights and freedom. Many cannot move from one village or state to another, as they lack the relevant identity documents, leaving them with nowhere to escape to.
Despite being denied citizenship, Rohingya men are – often forcibly – included in the rounds of recruitment by the Myanmar military, due to the announcement of a conscription law in February that applies to Myanmar citizens. At the same time, many other armed groups in Rakhine, including the Arakan Army, are also actively recruiting Rohingya. People from different communities expressed their fears of reprisal if they did not support one of the two opposing parties to the conflict.
Fighting for survival
It has now been over six months since MSF was last able to carry out its regular mobile clinics. Until recently, we were still trying to find ways to support communities by helping township hospitals with medical donations and assigning our medical staff. But then the township hospitals had to shut as they started running out of essential supplies of medicines and fuel to even have the hospital run, or to have the operating theatres’ run.
We are witnessing a near-total absence of humanitarian assistance in Rakhine state as people face relentless obstacles for their survival. Without any support, battling these is getting harder and harder.
The forced closure and targeting of health facilities, and the blocking of people’s access to health facilities, is unacceptable. Healthcare must be depoliticised and kept out of any political or military conflict.
In order to guarantee access to critical care and to reduce the risks of disease outbreaks in Rakhine, it is crucial that all parties to the conflict ensure healthcare structures can operate and that people can reach these facilities. Essential drugs must be allowed to be transported to save lives and respond to outbreaks and emergencies – including when it means crossing townships in Rakhine.
(c) 2024, The New Humanitarian
