Eight months since deadly communal clashes first broke out in Rakhine state, Myanmar, tens of thousands of people are still unable to access urgently needed medical care. Médecins Sans Frontières (MSF) calls on government authorities and community leaders to ensure that all people of Rakhine can live without fear of violence, abuse and harassment, and that humanitarian organizations can assist those most in need.

Humanitarian crisis in Rakhine State

"We are very worried about our women; we have more than 200 pregnant women in our camp. For their delivery they cannot go to a health centre and they will have to deliver here… in the mud without a doctor."

– Man living in a displaced persons camp in Pauktaw Township, Rakhine State

Rakhine state in western Myanmar is home to numerous ethnic groups including the Rakhine community, and a Muslim minority often referred to by the international community as the Rohingya.

Photo: Kaung Htet

Photo: Kaung Htet | Doctor from MSF medical team examines a child with diarrhoea at MSF clinic in a refugee camp on the outskirts of Pauk Taw township, on 3 February 2013. On that day, more than 80 diarrhoea cases were treated by MSF medical team.

In one of its biggest programs worldwide, MSF has been working across Rakhine state for nearly twenty years, providing primary and maternal healthcare and treating diseases such as malaria, HIV/AIDS and TB. Rakhine is Myanmar’s second poorest state and has historically received less investment in healthcare than other areas of the country. Over the years MSF has treated hundreds of thousands of people across the state regardless of ethnic origin or religious affiliation. In June 2012, deadly communal clashes in Rakhine State triggered an official state of emergency. An estimated 75,000 people were displaced - many had their homes burned down. Further outbreaks of violence in October exacerbated the humanitarian crisis, forcing an estimated 40,000 people to flee. Many ended up living in makeshift camps that lack sufficient shelter, water, sanitation, food and healthcare. According to official estimates, the vast majority of those displaced are Muslim. In addition, hundreds of thousands more people still living in their homes have had very limited access to healthcare because medical services were cut off. In many areas medical services have still not resumed. Thousands also fled, many to neighboring Bangladesh, where an estimated 300,000 Rohingya refugees already live. The majority is undocumented and live in deplorable condition. Many have struggled to survive for years. MSF provides healthcare outside one of the makeshift camps to unregistered refugees and to local Bangladeshis. Others went to Thailand and Malaysia. They say their main reason for leaving was to avoid extreme violence toward them and their families.

“I can swear that in front of my eyes, they killed a lot of people in my village… and I was the witness.”

– 15-year-old Rohingya refugee in Malaysia

Violence worsened already harsh conditions

Violence and displacement has worsened the already harsh living conditions that many people in Rakhine state were already suffering from, and further limited their access to healthcare. The stateless Rohingya lack basic rights and freedoms, are subjected to severe restrictions and abusive treatment. Their health situation has been unacceptably poor for years.

Malnutrition as well as maternal and primary health care needs have been acute amongst this community for many years, while gaps in official healthcare services are more pronounced in areas where Rohingya live. Since the outbreaks of violence, healthcare and other forms of humanitarian assistance - including services delivered by MSF - have been very slow to resume or start up in some of the worst affected areas. Delayed permissions, ongoing insecurity and repeated threats and intimidation by a small but vocal group within the Rakhine community have severely impacted on our ability to deliver lifesaving medical care where it is needed most.

Life in the camps

Following the clashes and amidst deep hostility, communities that were previously living side-by-side, and sometimes mixed, are now divided and separated. Many thousands of people – mainly from the Rohingya community – remain unable to return to their homes. It is among these people, living in poor conditions in rice fields or other crowded strips of land, that we are seeing the most acute needs. Since October, MSF has conducted more than 10,000 medical consultations through mobile teams in some of these areas. But medical needs are far from covered. MSF is currently working in 15 of the largest camps. We do not have the capacity to be in the dozens of other smaller camps, where conditions are likely to be equally poor. A big obstacle for MSF is not having enough staff - doctors and other essential personnel are too scared to work in Rakhine State. This fear is the result of sustained intimidation and threats against MSF workers by some members of the Rakhine community. MSF is alarmed that this health gap is still not being filled by the government or other organizations. We urge the government to do more to create a safe environment for humanitarian assistance, and to encourage medical staff from other parts of Myanmar to help provide emergency healthcare in Rakhine.

Malnutrition, chronic coughing and diarrhea

Where MSF has been able to run mobile clinics, the most common diseases we see are skin infections, worms, chronic coughing diarrhea and respiratory tract infections. Shelters are frequently inadequate, leaving people exposed and there are often not nearly enough blankets to go around. Severe malnutrition is also present, particularly amongst children in many of the camps. During one recent camp clinic, 40 percent of the children under-five that MSF saw were suffering from acute diarrhea.

“Our children are dying from diarrhea, we all have diarrhea; we need more health care. Our latrines are full. We can only dig holes up till 40cm and then we hit the salty water so what should we do? The nearest source of water where we dare to go is 40 minutes by canoe. We received only once since we are here [since October] a tank with drinking water.”

– Man living in a displaced persons camp in Pauktaw Township, Rakhine State

Photo: Kaung Htet
Photo: Kaung Htet. | Doctor from MSF medical team asking for the history of illness of a child with diarrhoea at MSF clinic in a refugee camp on the outskirts of Pauk Taw township, on 3 February 2013. On that day, more than 80 diarrhoea cases were treated by MSF medical team.

People being denied clean water too scared to try to reach it

Lack of access to clean water is likely to be the cause of the high rates of diarrhea. Although there is plenty of clean water available, many of the displaced are being denied access to it.

“The only drinking water pond we have is the one which we have to share with the cattle of the nearby village. Five minutes from here is a pond with crystal clear water. We don’t dare to go.”

– Man living in a displaced persons camp in Pauktaw Township, Rakhine State

The vulnerability of those living in the camps is exacerbated by confinement. People are scared to leave or are at times prevented from leaving, out of fear of abuse or attack by hostile groups.

Medical referrals a serious challenge

Patients who are too sick or injured to treat on the spot need to be sent to hospital. The options for referring them are, however, very limited. Patients and those transporting them often face hostility and intimidation. This compounded by major logistical challenges, means that delays can be life threatening.

“I cannot get my TB treatment anymore so I had to stop. Before the violence I went to the township hospital. Now I cannot go anymore.”

– Man from Kyauktaw Township

Threats and intimidation need to be addressed

The horrific conditions in the camps and the severe impediments to medical referrals underscore the need for the Myanmar authorities to ensure all people living in Rakhine are protected and have access to lifesaving assistance In pamphlets, letters and Facebook postings, MSF and others have been repeatedly accused of a pro-Rohingya bias by a small but vocal and influential group within the Rakhine community. One community leader recently described MSF’s medical aid to displaced persons outside their village as watering a plant, a plant he does not want to see watered. It is this intimidation, and not formal permission for access, that is the primary challenge MSF and others seeking to provide lifesaving humanitarian assistance face. The authorities can do more to make it clear that threatening violence against health workers is unacceptable.

MSF is impartial, providing medical assistance where it is needed most

As an impartial medical humanitarian association, MSF provides medical assistance to those in need, irrespective of ethnicity, religion, creed or political convictions. We base our programs on independent, impartial assessments that seek to provide medical care where it is needed most. This is how we have operated throughout Myanmar and in Rakhine State for the past twenty years. The result has been that hundreds of thousands of people from all ethnic groups have been treated for diseases such as malaria, HIV/AIDS and TB. Yet the threats continue. Being impartial means providing care where it is most needed, regardless of where patients come from, or what they believe in. The assistance that MSF and others can provide is being dangerously hampered by the hostility we face, leaving tens of thousands of people living in desperate conditions without adequate help.

We urge the Myanmar authorities to provide greater protection to threatened groups and to help defend our commitment to bring assistance to those in need. MSF has been providing healthcare around the world and in Myanmar for decades, meeting the medical needs of millions of people hailing from countless ethnic origins. Across Myanmar, MSF provides more than 26,000 people with lifesaving anti-retroviral treatment for AIDS and was amongst the very first responders to cyclones Nargis and Giri providing medical assistance, survival items and cleaning water sources for tens of thousands of people. MSF has worked for the past twenty years in Rakhine State,  providing primary and reproductive health care as well as HIV/AIDS and TB treatment. Prior to June, MSF had been conducting approximately 500,000 medical consultations annually. Since 2005 MSF has treated more than 1.2 million people from all ethnic groups in Rakhine State for malaria.

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