Health care in Malaysia's twilight zone

The migrants often live in a twilight zone, with no official status and no rights to fall back on.

Malaysia, with its booming economy and surrounded largely by poorer nations, attracts high numbers of migrants. Many of them come to find work in construction or agriculture. Others have fled violence and persecution in their home countries, like Myanmar or Indonesia's Aceh province. They often live in a twilight zone, with no official status and no rights to fall back on. They also have difficulty accessing health services. In 2004, Medecins Sans Frontieres (MSF) started providing basic health care to migrants, mostly those from conflict areas and countries with oppressive regimes. The project is due to be handed over to Malaysian organisations at the end of March.

When the MSF team arrives at the buildings where they will set up a clinic for the day, dozens of people are already waiting. The team comes here every week to offer medical consultations and psychological help to those who cannot afford to go the regular health structures; the costs are too high and people without the right documents risk being turned in to the police or immigration officials. In this particular clinic, most people who come for a consultation are from Myanmar.

"My husband joined the Karen National Union," says a 22-year-old woman from Myanmar. She is sitting on a bench in the shade, rocking her baby girl of one month, waiting for her turn to see the doctor. "I did not want him to leave home, but I agreed with his principles. He died in battle. After that, the authorities started to come to my home, looking for him. They did not believe he was dead. They threatened me often. I had nowhere to go, as my father passed away many years ago. So I decided to flee."

The woman's story is typical for many of the people who visit the clinic today. Fleeing an oppressive regime, they pay huge sums of money to trafficking agents who arrange for transportation from Thailand, just across the border with Myanmar, into Malaysia. This woman was luckier than most in that her agent also found her a job, albeit in the illegal sector. Changing coins for visitors in a games parlor, she could do her job sitting down. Just as well, as she was already five months pregnant by then.

The MSF team has installed the basic facilities they need to run the clinic. They work fast, to allow as many people as possible to be examined. Under a roof, protected from the scorching sun, two team members register the people. They take down some basic information and give them a docket with their number. Across the yard, people wait outside what looks like a classroom for their number to be called. There is only one doctor, Susheela Balasundaram, and many people have to wait a long time. Nobody complains.

Dr Balasundaram will see some 80 patients today, but manages to give everyone the personal attention they need. Assisted by her interpreter, she checks people's health in a corner of the room, over a simple table. For examinations that require more privacy, there is a bed with a screen. It is here that she carefully examines the belly of a woman in her ninth month of pregnancy. This woman, also from Myanmar, is due to give birth in 10 days but it's the first time she's had an antenatal check. Luckily, everything seems to be fine.

"Life back home was way too expensive," she explained. "We had virtually no income. We would only have meat once a month. My father had a small plot of land and grew food. When he died, the government took the land back; they own all the land. If I had wanted to use my father's lot, I would have had to rent it. I could not afford this. I left because I had to survive."
She met her husband in Malaysia and was soon pregnant. However, she could not see a doctor because she did not have the right documents. "When my husband's brother had an accident, he lost his job. He, too, has no papers. My husband took him to hospital and we had to pay for everything. We still have big money problems because his brother is still ill and he is living with us."

All foreigners pay the same fees in Malaysia's surgeries and hospitals, about twice the rate for Malaysian citizens. This may not be a problem for American, European or Australian tourists and businesspeople, but the costs are much higher than most undocumented migrants can afford.

Although Malaysia has not signed the Refugee Convention it allows the UN to give refugee cards to some people, mainly those who can travel on to a third country. Those who are lucky enough to carry a UN card get a 50 per cent discount at health facilities; but it is a discount from the foreigners' rate. The fees are still prohibitive for many of these migrants.

And there is the fear factor. Medical staff are supposed to report people without proper paperwork to the police. And they often do, particularly in the public health centres. No wonder then, that large numbers of people have come to rely on aid organisations for their health care.

A team of psychologists and trauma counsellors are at the MSF clinic. People who show elevated levels of stress are advised to talk to one of these specialists. Post-traumatic stress is very common among the refugees. They have not recovered from their horrible experiences in their homeland. The flight to Malaysia will have only added to the stress: the 22-year-old had to hide in the bushes at the border while police dogs were combing the area for illegal migrants, and the 29-year-old was locked in the boot of a small car with four other people, barely able to breathe.

And then there is the stress of living in Malaysia's twilight zone: the constant fear of arrest, poor living conditions that cause skin diseases and breathing difficulties, and the insecurity of irregular employment.

Today's clinic, which also includes a pharmacy, is one of many set up by MSF in and around Malaysia's capital city. The locations range from a tiny downtown apartment to 'jungle sites', locations where groups of migrants have built a little shelter in the forest from discarded wood and other waste materials.

Malaysian non-governmental organisations are ready to take over these activities. "I think this project has already made a great difference," said Dr Balasundaram. "It has given people a place to turn to without reasons for fear or bills they cannot pay. For me, as a doctor, it has been rewarding to combine care for individual patients with the task to monitor the major health issues among this population as a whole. And I am really happy that I'm part of a team that gives health services to people who otherwise would have no, or very limited, access to medical care."