RANGOON — Government-imposed restrictions on Muslim communities in Arakan State are preventing tens of thousands of people from accessing medical services, not only in camps for displaced persons, but also in rural communities affected by the outbreak of communal violence more than a year ago, health care providers say.
Médecins Sans Frontieres (MSF),an international medical humanitarian organization that has worked in Arakan for nearly 20 years, says that since violence broke out last year between Buddhists and Muslims, its patient numbers in the state have dropped significantly, largely due to travel restrictions on Muslims that have been widely criticized as discriminatory and in violation of human rights.
Prior to the violence, MSF conducted about 250,000 medical consultations in the state over a six-month period in 2011, according to Vickie Hawkins, the organization’s deputy head of mission in Burma. But in the first six months of this year, she said MSF conducted only about70,000 consultationsin the state, “a significant drop-off.”
The decrease in patient numbers is partly because MSF, like other health care providers in the state, has had to change its strategy since the violence—shifting from fixed medical clinics to mobile clinics in order to reach internally displaced persons (IDPs) in temporary camps as well as patients in remote rural communities who cannot travel to see a doctor due to travel restrictions or fears for their safety.
“We are reliant on this mobile strategy, which basically means that you visit a community once a week, at best,” said Hawkins, adding that her organization serves 27 communities directly affected by last year’s violence, including inside and outside IDP camps. “Before, communities were able to access rural health centers, midwives and the township hospitals when they needed to—it wasn’t just when we came to them.
“Movement restrictions have been imposed for security reasons, to prevent the outbreak of further violence between the communities,” she added. “But that means there are many tens of thousands of people in Rakhine who were accessing the public health care system before and now aren’t.”
Many patients in the state, which is also known as Rakhine, have had to discontinue treatment for chronic illnesses, she said. As of late May, about 380 tuberculosis patients had visited one MSF clinic on the outskirts of the state capital Sittwe this year, and the majority of them had seen their treatment interrupted after the violence, she said.
“We’re seeing people die unnecessarily of things that could be treated if they had regular and systematic access to health care,” she said, citing deaths from tuberculosis, diabetes and complications from childbirth. “It’s avoidable mortality.”
“The tension and sort of fear that exists in Rakhine today is impacting both communities,” she added. In some instances, she said, although they do not face state-imposed restrictions on movement, Buddhists have also been afraid to travel for health care due to concerns for their safety.
Sectarian violence between ethnic Arakanese Buddhists and Muslims last year killed about 200 people and displaced 140,000 more. Most of the victims were from a minority Muslim group known as the Rohingya, who face severe discrimination in the country and are denied citizenship by the government.
An estimated 800,000 Rohingyas live in Arakan State, and although many trace their roots in the country back generations, they are widely seen among Buddhists as illegal immigrants from neighboring Bangladesh and have long been denied basic rights from the government.
After clashes first broke out in June last year, the government imposed restrictions on the movement of Rohingyas in townships around Sittwe, where many of the IDP camps are located. Those restrictions were intensified after fighting was renewed in October.
Beyond the makeshift shelters of IDP camps, in villages around Sittwe and in northern areas of the state, where many Rohingyas live, MSF says restrictions on movement have left whole towns almost entirely cut off from health facilities.
Mobile teams of doctors travel great distances to reach some of these isolated communities, but cannot always offer reliable or frequent services. “Some of the sites we reach by boat—it can be quite a long journey—and now that we’ve got the rainy season, boats are subject to cancellation if the weather conditions are bad,” Hawkins said. “By the time we get there, you can’t run an eight-hour clinic—you’re looking at a four-hour clinic, at best.”
MSF now operates six mobile clinics in the state and three fixed clinics that provide mainly malaria and tuberculosis services in the bigger camps in Sittwe Township. This is a change from before the violence, when it operated six fixed clinics and just one mobile clinic. “We undoubtedly have less capacity than we used to in Rakhine,” Hawkins said. “We suspended the majority of our activities at the time of the violence in June and since then we have had to respond to where the needs are greatest.”
Burma’s Health Ministry also operates mobile services in the state, as does the Myanmar Medical Association (MMA), the largest network of private doctors in the country.
With support from the United Nations Population Fund (UNFPA), the medical association launched three mobile clinics and one fixed clinic after the outbreak of violence last year. Those clinics saw more than 1,800 patients in May, according to data provided by the UNFPA.
“Clinics providing services to Muslim communities in IDP camps in Sittwe are much more crowded than clinics providing services to the Rakhine community in IDP camps in Sittwe,” Dr. Mukesh Prajapati, the humanitarian affairs specialist at the UNPFA, told The Irrawaddy. “This is also because there are more Muslim IDPs than Rakhine IDPs in Sittwe.
“Restrictions on the movement of Muslim communities affect access to health and medical care, particularly during medical emergencies,” he added.
The International Committee of the Red Cross (ICRC) last year also began providing transportation services for patients to and from Sittwe Referral Hospital for emergency services and consultations. In collaboration with the Myanmar Red Cross Society, the ICRC has transported nearly 1,000 people, mostly Muslims but also Arakanese Buddhists, through this service since January, according to Bart Vermeiren, the ICRC deputy head of delegation in Burma.
“It was needed to protect the patients of whatever ethnicity, race or religion,” he said of the service, which now operates 24 hours daily.
Burma’s national health system has been chronically underfunded for decades and in Arakan, one of the country’s poorest states, the violence and mass displacement are testing the limits of already strained resources.
Midwives provide the bulk of health services in Burma’s rural areas and are responsible for about 3,000 patients each in some states. In Arakan State, there are fewer than 30 midwives per 100,000 people, according to the latest publicly available statistics from the Health Ministry in 2009.
After the outbreak of violence, many midwives stopped traveling to certain rural villages due to security fears.
The ICRC is communicating with the Health Ministry, regional health directors and the midwives themselves to see whether it can help support the transportation costs of midwives. “But it’s a negotiation,” Vermeiren added. “We cannot just impose—you cannot just push health care workers to go back.”
Aid organizations have also faced challenges recruiting health care workers. MSF says its staff have faced intimidation from local residents in the state for helping Muslims, although the organization serves patients of all ethnicities and religions.
“It’s very difficult to mobilize staff today to work in Rakhine,” Hawkins said. “We’ve had instances of staff threatened by community members, and nationally, people can come under pressure from family and friends not to work there.”
The climate of hostility has eased in recent months and MSF is no longer subject to the same level of intimidation it faced previously, she added, “but that doesn’t mean the problem has gone away completely.”
Burma’s government said this week that US$66 million in international aid had been allocated to relieve the situation in Arakan State.
The ICRC on Monday announced that it was appealing to donors for about US$8.8 million in additional funding for Burma—bringing its total budget for the country to about $16.4 million— with the extra funds mainly allocated to assist those hardest hit by the violence in Arakan. The UN’s Central Emergency Response Fund, which has provided more than $15 million for the humanitarian situation since June 2012, in April gave the UNFPA a grant of $150,000 to strengthen health services in the state through the support of mobile teams and referral services.
Government authorities this week also defended the travel restrictions on Rohingyas.
“We have tightened security for Bengali people at their camps. We blocked them from traveling to areas where there are Arakanese in order to avoid further violence,” Hla Thein, an Arakan State government spokesman, told dozens of diplomats, UN officials and aid workers gathered for a briefing at the Foreign Ministry on Tuesday. The government refers to Rohingyas as Bengali.
“We just protect them for security reasons. We are worried that some people misunderstand our intentions,” he added.
MSF is communicating with the Health Ministry to push for more investment in fixed clinics, but says other government authorities are responsible for the travel restrictions.
“We have a very strong dialogue with the Ministry of Health in Rakhine and we are working in a very collaborative way with them, but movement restrictions are imposed for security reasons, and that is not under the remit of the Ministry of Health,” Hawkins said.
“Certainly we are talking with the government about a minimum freedom of movement to allow people to reach health care services. And it may be that new structures need to be built and that’s what we are very willing to do if necessary to ensure health care can reach those who need it.”
Additional reporting by Lawi Weng.