Nargis: A window to wider health issues

"Many people said this years festival of lights was the best ever! It didn't start that well – at first people were concerned that they did not have the candles or the means to celebrate. However, our counselors encouraged women to form groups and to pool resources. The result exceeded everyone's expectations and provided a symbol of hope for the future". Ruth Ulrich, MSF Mental Health Officer, Irrawaddy Delta.

Six months have passed since cyclone Nargis devastated Myanmar's Irrawaddy Delta, leaving an estimated 130,000 people dead or missing and altering the region immeasurably. The scars it left behind remain evident today, not least in the minds of the survivors and their ongoing vulnerability. Nutrition, the availability of drinkable water and livelihoods remain key concerns, especially in some harder to reach areas.

The people of the Delta, however, have demonstrated great resilience and signs of improvement are visible. An unprecedented number of international non-governmental organizations (INGOs), working alongside the state authorities, have done much to stabilize the situation and continue to provide essential support for people's ongoing recovery.

As such, Medecins Sans Frontieres (MSF) is now able to hand over many of its programmes to other actors, while continuing to work in some lesser assisted areas of concern. In distinct contrast, elsewhere in the country we continue to battle against chronic and urgent health needs, compounded by a lack of investment by both the government and the international community alike. This selective blindness to countrywide needs, not least in the areas of HIV/AIDS, Tuberculosis and Malaria to mention a few, continues to cost the lives of thousands of people year upon year, without ever grabbing the headlines.

A symbol of hope for the Irrawaddy Delta

MSF began its emergency intervention just hours after the cyclone hit Yangon and was providing assistance in the city and in the Delta within 48 hours. Since then, around 750 (rotating) staff has assisted more than 550,000 people in responding to their emergency needs; providing food, shelter, water, healthcare, psychosocial support and essential non-food items.

"From the outset we worked together with communities to get the emergency aid where it was needed. Our first team encountered four villagers on motorbikes who immediately wanted to help - refusing pointblank any payment. Together they were quickly able to deliver food to numerous places", told MSF Head of Mission Frank Smithuis. Six months later and life for many people in the Delta seems to be slowly improving. Villagers can be seen rebuilding their homes and at work in the paddy fields. The health of the surviving population is similar to that of people throughout rural Myanmar and to date our medical teams have not seen the feared outbreaks in disease or escalation in malnutrition.

"Seeing people active is a good sign", explains MSF Mental Health Officer Ruth, "initially people were unable to work, they were too traumatized. But the trauma symptoms such as sleeplessness and flashbacks are now reducing". MSF's psychosocial programme has sought to support more than 21,300 people to better cope with the experience through individual and group counseling, community work and mental health education. "People are still concerned", adds Ruth, "but about practical things like water, livelihoods and the next harvest". MSF repaired many wells and water ponds, but the rainy season is now coming to an end and people are concerned about having enough drinkable water to see them through the dry season. Likewise, people fear that the coming harvest will not suffice, as the planting was too little too late and many of the water buffalo that used to work the fields were killed in the cyclone.

"People's emergency needs in the Delta have been met", explains MSF Project Coordinator Emily Bell, "What they now require is ongoing support for their long-term recovery, as they have been rendered highly vulnerable. Thankfully, there are now many NGOs present, enabling MSF to hand over the majority of our programmes. However, adequate support remains limited in some harder to reach areas, particularly in the southern parts of Bogaley Township. In these places we will continue to provide assistance in the short-term, whilst encouraging increased support from other actors".

The struggle to get an appropriate level of assistance for Myanmar's most vulnerable people is one that affects the whole country. "MSF continues to tackle critical health issues throughout Myanmar. Diseases such as HIV/AIDS, Tuberculosis and Malaria cause untold suffering for countless people, and there remains a gross lack of assistance by all care providers", says Emily.

Beyond the Delta

"I want all HIV patients to be helped in the way that people have helped the Nargis cyclone victims. When Nargis happened, people all over Myanmar and other nations came in to help. I want them to help HIV patients the same way". MSF HIV Patient

HIV sufferers face a critical situation in Myanmar, with an estimated 240,000 people thought to be infected with the disease and 24,000 AIDS related deaths in 2007 alone. A similar number of people are expected to suffer the same fate in 2008, due to the inaccessibility of lifesaving anti-retroviral treatment (ART).

"I simply cannot afford to buy it and so I must accept that I will die - I have no other choice", told a 28year old MSF patient. He arrived at one of the organization's Yangon clinics not long after MSF had been forced to cap the number of people for whom they could provide ART.

"MSF currently provide ART to more than 11,000 people countrywide, with thousands more registered to start when needed. That is 80% of all available treatment in Myanmar, but it is simply not enough. The lack of response by other actors has pushed MSF to its limit and now we must go through the painful process of telling people they have HIV but that we cannot treat them. It is heart wrenching", explains an MSF doctor.

Currently the Government of the Union of Myanmar (GoUM) treats around 1,800 patients with ART, whilst other INGOs engage in HIV care but very few provide treatment. An estimated 75,000 people urgently need ART but cannot access it. "Provision of care is important for people’s recovery, but without ART a patient cannot recover, many people are dying unnecessarily", adds the MSF doctor.

The 2006-2010 National Strategic Plan on AIDS, issued by the GoUM with the support of UN and other NGOs, offers a sound basis for rolling out appropriate levels of care, however the situation as it stands is unacceptable.

HIV is just one of a number of treatable epidemics that causes Myanmar to have some of the worst health statistics in Southeast Asia. Out of its 11 neighboring countries Myanmar has the lowest life expectancy at birth and the highest rates of neonatal and under-five mortality. Malaria remains the number one killer, with deaths in the country equaling more than half of those in Southeast Asia as a whole. Further, more than 80,000 new tuberculosis cases are detected each year (among the highest rate worldwide) and multi-drug-resistant TB is on the rise. In certain parts of the country, such as Rakhine State where the Muslim population is heavily discriminated against, the health statistics are even worse. The critical need for increased healthcare is evident, yet the lack of investment from both inside and outside of the country remains grossly insufficient.

Official sources alone reveal chronic under-funding of the health infrastructure. State health expenditure per person in 2007 was just $0.7 USD , and a meagre 0.3% of the country's Gross Domestic Product , a sum that is disproportionate to both the extent of the needs and the countries overall resources. Similarly, the level of international humanitarian aid is strikingly low, around $3 USD per person , the lowest rate worldwide and significantly different to the far greater amounts received by nearby countries facing similar epidemics.

Nargis, in all its horror, threw Myanmar back into the international spotlight and brought to the forefront some of the complex issues around providing humanitarian assistance to the country. It clearly demonstrated that delivering humanitarian assistance in Myanmar is not easy, due to numerous limiting factors; not least controlled access, overbearing administration and the highly politicized environment.

But more importantly, it demonstrated that providing humanitarian assistance in Myanmar is possible, as MSF has been doing for the past fifteen years without sacrificing either independence or accountability. The task may not be easy but it is unarguably critical if people are to receive the care and support necessary to live healthy and dignified lives.

Likewise, the authorities need to increase their efforts to assist those in urgent need of assistance and to facilitate the activities of others who work to do so. The health needs of countless people throughout the country require immediate attention in order to prevent unnecessary suffering. This is not about politics it is about saving innocent lives. If ever there was a window through which to re-visit our collective responsibility to the people of Myanmar it is now!

Notes:
1) UNAIDS, 2007
2) Ibid
3) Government of the Union of Myanmar, Department of Health, 2007
4) United Nations Development Programme, 2008
5) Organisation for Economic Cooperation and Development, 2008