Chapter 4: Health
Chapter 4: Health
- Access to healthcare has been a significant concern throughout 25 years of KHRG reporting. Access to healthcare for villagers has been deliberately denied through Tatmadaw’s imposed restrictions on freedom of movement and the trading of medical supplies in the 1990s and 2000s. Since the 2012 ceasefire, barriers in accessing healthcare have changed from conflict-related to infrastructure-dependent, including the lack of adequate roads to rural areas, and the lack of functioning healthcare facilities in rural areas.
- Displaced villagers suffer disproportionately from a lack of access to healthcare and medical supplies when in hiding. Due to severe restrictions on villagers’ movement, sickness, malnutrition and disease are estimated to have killed more people throughout the conflict than the direct violent abuses of Tatmadaw and EAGs.
- When healthcare facilities are available and accessible, patients report that they are frequently understaffed, lack essential medical supplies, and operate unreliable opening hours. Additionally, villagers have raised complaints about the acceptability of healthcare standards, particularly those made recently available since the 2012 preliminary ceasefire. They have experienced disrespectful and discriminatory Myanmar government healthcare staff, lack of information on the side effects of medicine prescribed, and arbitrary denial of treatment.
- The standard of healthcare services, when made available, has been consistently low throughout 25 years of KHRG reports, particularly in rural areas of southeast Myanmar. Villagers have relied on traditional medics and traditional medicines, most especially during conflict and when in hiding, but this dependence continues in areas which are not served by permanent healthcare staff and in areas where medical supplies are not available.
- Significant financial barriers persist with regard to free and equal access to healthcare. The financial consequences of Tatmadaw, BGF and EAG abuses, including financial extortion and a lack of time for villagers to work for their own livelihoods, left many villagers financially insecure and unable to pay for basic medicines. Whilst these abuses have reduced, villagers report that they continue to find healthcare inaccessible due to financial barriers including the cost of travel to hospitals, the cost of medicine, and the unwillingness of some healthcare staff to treat poorer patients.
This photo was taken on January 18th 2017 in Taung Soe village, Si Pyay village tract, Win Yay Township, Dooplaya District. This photo shows a local clinic in Taung Soe village. According to villagers, there are not enough health workers at this clinic and the health workers do not always stay at the clinic so villagers continue to face troubles when they are sick. [Photo: KHRG]
This photo was taken on November 29th 2015 in Tha Main Dwut village, Tha Main Dwut Village Tract, Kawkareik Township, Dooplaya District. It shows a clinic constructed by the Myanmar government health department. However, since the clinic was constructed there have been no health workers or medicines. For these reasons, villagers couldn’t use it. [Photo: KHRG]
This photo was taken on June 6th 2016, in Cow Thaw Cow village, Hon Thaw Plo village tract, Thandaunggyi Township, Toungoo District. It shows a KDHW clinic with health administrators who operate under the KNU health department. The health workers do not have enough medicines however they try to take care of local villagers as much as they can. [Photo: KHRG]
This photo was taken on November 11th 2016 in Tha Main Dwut village, Tha Main Dwut village tract, Kawkareik Township, Dooplaya District. It shows members of the Backpack Health Worker Team (BPHWT) trying to help sick villagers by giving them medical treatment for free in Tha Main Dut village. [Photo: KHRG]
This photo was taken in September 2014. It shows a clinic that was built by the Myanmar government in order to improve the health of the villagers in Kah Lee Kee village, Kyainseikgyi Township, Dooplaya District. In the past year villagers report that they have suffered from various diseases and that some villagers have died for treatable diseases. However, they report that the health situation is getting better compared to the past because now the clinic is available in the village. [Photo: KHRG]
This photo was taken on April 20th 2014 in Kyoh Kah Loh village, Htee Th’Daw Htah village tract, Buh Tho Township, Hpapun District. This photo shows a clinic constructed by an unknown NGO, with some involvement from the Myanmar government. The clinic was completed in 2012. This clinic aims to help villagers to get access to healthcare close to their area but until now villagers have not seen any medicine, only clinic construction. Villagers at the time this photo was taken did not have any information about whether they will get medicine in this clinic or not. [Photo: KHRG]
This photo was taken on December 27th 2014 at Leik Tho Town, Thandaunggyi Township, Toungoo District. It shows a free healthcare service provided at the public hospital. The service is led by the local KNU government and medical specialists. [Photo: KHRG]
This photo was taken on April 19th 2014 in Meh Lah Htah area, Htee Th’Daw Htah village tract, Bu Tho Township, Hpapun District. It shows a women suffering from an unknown illness. She cannot access proper treatment or prescription medicine due to the cost of travel and treatment, and the distance to the hospital. Instead her husband is making a traditional herbal and leaf medicine for her. [Photo: KHRG]
IDP villagers in Lu Thaw Township, Hpapun District are shown here on March 4th 2009, having come to D--- IDP camp in order to receive medical treatment from a mobile Karen medical team. Such aid, delivered by local Karen staff working with small mobile medical teams which obtain supplies from across the border in Thailand remains crucial means by which IDP communities are able to address their health needs. [Photo: KHRG]
This picture, taken on September 10th 2009, shows 39 years old convict porter Maung Tha---, who escaped after being taken from prison and forced to carry supplies for LIB #212. Maung Tha--- had been serving a 7 years term. He was sent to act as a porter on December 5th 2008. He told KHRG he escaped because he could no longer bear the heavy loads and verbal and physical abuse by soldiers. On his right shoulder can be seen scars from sores developed while carrying his loads. [Photo: KHRG]
This photo from a 2000 KHRG report shows the body of villager Saw Maw Toh from K--- village in western Lu Thaw township, Hpapun District. Saw Maw Toh, aged 40, had fled with other villagers when Light Infantry Division #66 destroyed their village, but then died of illness in the forest because there was no medicine. He leaves a wife and 2 children aged 1 and 9. [Photo: KHRG]
This photo from a 2000 KHRG report shows a sick villager staying in his hiding place Mone Township, Nyaunglebin District, unable to leave to access medicine. Tatmadaw troops had been sweeping their area since November, causing many villagers to go into hiding. This villager has been sick but has not got medicine. Thousands of internally displaced villagers were living in hiding in the forested hills with little food and no medicines during this time, dodging Tatmadaw patrols which systematically destroyed their shelters and food supplies. [Photo: KHRG]
This photo shows a mother and her son in Kwih Kaneh Khoh village, Kyainseikgyi Township, Dooplaya District, November 1996. On 27th October 1996 a column of Tatmadaw troops attacked and looted Kwih Kaneh Khoh village, Kyainseikgyi Township, Dooplaya District (southwest of Kyaikdon). The village was completely undefended and the troops marched into all 30 houses and looted everything, leaving the villagers with nothing. Just afterwards this woman’s son fell sick, and when this photo was taken 3 weeks later he could no longer move. Tatmadaw does not allow medical supplies to enter this area. [Photo: KHRG]
This photo from a report by KHRG in 1997 shows Maung PQ---, aged 28, a Muslim villager from Myawaddy Township, Dooplaya/Hpa-an District, who was taken as a frontline porter in 1996 even though he was already sick with malaria. Two weeks later he collapsed under his 40-kilo load of mortar shells, so he was kicked and beaten unconscious by the commander and kicked down a slope to die. Other porters escaped later and returned to find him and carry him to Thailand. Doctors operated 3 times, drained 1.5 litres of pus from his arm and thigh, and found he had a permanent corneal scar, a broken rib, serious damage to his arm, and the muscles of his thigh were so badly beaten that he will never walk properly again, all from the beatings. He was not even strong enough to be interviewed until one month later. [Photo:KHRG]
This photo, taken in eastern Nyaunglebin/Hpapun District, shows a woman who had fled her hill village due to Tatmadaw attacks in 1997. The woman is hiding in a forest shelter and had been down with serious dysentery for several days. She had no medicine, and could die from this illness.[Photo: KHRG]
This photo from a 1994 KHRG report shows a sick and malnourished baby Karen girl in Thaton district. Infant mortality in these areas was extremely high due to Tatmadaw offensives, looting, extortion, and the Tatmadaw blockade against any medicines entering this ‘insurgent’ area. [Photo: KHRG]
 “Thaton Situation Update: Thaton Township, January to June 2015,” KHRG, January 2016.
 Article 25, “Every one has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.” “Universal Declaration of Human Rights,” United Nations General Assembly, December 1949. Myanmar was one of the first countries to vote in favour of adopting this non-binding Declaration.
 Article 12, “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the high estattainable standard of physical and mental health.”“International Covenant on Economic,Social and Cultural Rights,” United Nations General Assembly, 1966. Myanmar signed the ICESCR in July 2015.
 “CONSTITUTION ON THE REPUBLIC OF THE UNION OF MYANMAR,” September 2008.
 The killing or denial of medical treatment to the wounded in conflict is a grave breach of the Geneva Convention of 1949, see Article 3.2: “The wounded and sick shall be collected and cared for.” Geneva Convention, 1949.
 Article 18, “Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.”“Convention (IV) relative to the Protection of Civilian Persons in Time of War,” International Committee of the Red Cross, August 1949. See also “Customary IHL: Rule 28. Medical Units,” International Committee of the Red Cross, 2012.
 Source #165.
 Tatmadaw refers to the Myanmar military throughout KHRG’s 25 years reporting period. The Myanmar military were commonly referred to by villagers in KHRG research areas as SLORC (State Law and Order Restoration Council) between 1988 to 1997 and SPDC (State Peace and Development Council) from 1998 to 2011, which were the Tatmadaw-proclaimed names of the military government of Myanmar. Villagers also refer to Tatmadaw in some cases as simply “Burmese” or “Burmese soldiers”.
 In Burma/Myanmar, the scorched earth policy of ‘pyatlaypyat’, literally ‘cut the four cuts’, was a counter- insurgency strategy employed by the Tatmadaw as early as the 1950’s, and officially adopted in the mid-1960’s, aiming to destroy links between insurgents and sources of funding, supplies, intelligence, and recruits from local villages. See Martin Smith. Burma: Insurgency and the Politics of Ethnicity, New York: St. Martin’s Press, 1999 pp. 258-262. See also, “GRAVE VIOLATIONS: ASSESSING ABUSES OF CHILD RIGHTS IN KAREN AREAS DURING 2009,” KHRG, January 2010; and “Attacks and displacement in Nyaunglebin District,” KHRG, April 2010.
 “Papun and Nyaunglebin Districts, Karen State: Internally displaced villagers cornered by 40 SPDC Battalions; Food shortages, disease, killings and life on the run,” KHRG, April 2001; see also “Photo Set 2002, Section 2: Attacks on Villages and Village Destruction,” KHRG, December 2002. Attacking medical units is recognised as a grave breach of customary international humanitarian law. See, “Rule 28. Medical Units,” International Committee of the Red Cross, 2012. It is a breach of the Fourth Geneva Convention, Article 18, “Civilian hospitals organized to give care to the wounded and sick, the infirm and maternity cases, may in no circumstances be the object of attack but shall at all times be respected and protected by the Parties to the conflict.” “Convention (IV) relative to the Protection of Civilian Persons in Time of War,” International Committee of the Red Cross, August 1949.
 Source #115; see also “[The two biggest challenges facing the community are] [h]ealth and conflict between Tatmadaw and other ethnic armed groups. These two things are important.”Source #168.
 Tatmadaw expert Maung Aung Myoe explains that the three-phased Tatmadaw counter-insurgency plan, developed in the 1960s, designates a territory as black, brown or white according to the extent of ethic armed group (EAG) activity. Phase one transforms a ‘black area’ into a ‘brown area,’ meaning it transforms from an area controlled by EAGs where the Tatmadaw operates, to a Tatmadaw-controlled area where EAGs operate. The second phase is to transform the area from a ‘brown area’ into a ‘white area,’ where the area is cleared of insurgent activities. The final phase is to transform a white area into a ‘hard-core area,’ during which more organisational works are necessary and the government forms pro-government military units for overall national defence. See Maung Aung Myo, Building the Tatmadaw: Myanmar Armed Forces Since 1948, Singapore: Institute of Southeast Asian Studies, 2009, p. 31-32; see also Neither Friend Nor Foe: Myanmar’s Relations with Thailand Since 1988, Singapore: Institute of Defence and Strategic Studies Nanyang Technological University, 2002, p. 71.
 These restrictions were reported by KHRG as recently as 2009 in Toungoo District: “OnNovember20th,2009,MOC#5beganblocking villagersfromKlerLaandGkawThayDer, TantabinTownshipfromtravellingontheroad to Toungoo.This occurred ata time when such a large number of individuals from areas around Kler La and Gkaw Thay Der were suffering from the flu and other winter illnesses that the Kler La hospital was full to the point of turning away patients. The movement restrictions prevented individuals from villages without medical facilities or medicines from travelling to Kler La to seek treatment, while preventing individuals already in Kler La but not admitted to the hospital from travelling to other towns or cities to get treatment or medicines. The situation was reported to SPDC [Tatmadaw] officials but the restrictions were not adjusted or relaxed. Such restrictions, which are particularly harmful for vulnerable populations such as children in need of medical treatment, are considered a ‘grave violation’ of children’s rights and explicitly condemned by United Nations Security Council Resolution (UNSCR) 1612.” “Forced Labour, Movement and Trade Restrictions in Toungoo District,” KHRG, March 2010.
 “The SLORC/SPDC Campaign to Obliterate All Hill Villages in Papun and Eastern Nyaunglebin Districts,” KHRG, February 1998; see also “Toungoo Situation Update: April 2011,” KHRG, June 2011; “ATTACKS ON KAREN REFUGEE CAMPS,” KHRG, March 1997.
 “The prohibition on carryingmedicinemeans that it must be bought and carriedsecretlytothe villages.The carrier risksbeingaccusedofsupplyingmedicinetotheresistanceandprobableexecution.”“PEACE VILLAGES AND HIDING VILLAGES: Roads, Relocations, and the Campaign for Control in Toungoo District” KHRG, October 2000; see also “Papun and Nyaunglebin Districts, Karen State: Internally displaced villagers cornered by 40 SPDC Battalions; Food shortages, disease, killings and life on the run,” KHRG, April 2000.
 “Forced Labour, Movement and Trade Restrictions in Toungoo District,” KHRG, March 2010.
 “They didn’t provide food [at the relocation site]; the people had to bring their own food to eat. If you want to take medicine, you haveto buyitand ifyou don’t buy it, you can’thavemedicine.Sometimes youcantrade itfor chicken:2 tablets of para [Paracetamol] for ½ viss of chicken. But they don’t give it to you for free. You have to trade with the Burmese soldier’s medic.” “STARVING THEM OUT: Forced Relocations, Killings and the Systematic Starvation of Villagers in Dooplaya District,” KHRG, March 2000.
 “Tenasserim Division: Forced Relocation and Forced Labour,” KHRG, February 1997; see also “INCOMING FIELD REPORTS,” KHRG, August 1994.
 See, for example, the testimony of Saw Eu---, 27 years old who was forced to porter in 1992 and saw 4 fellow porters be left behind to die due to weakness: “Isawit4 times. The men got malaria and couldn’t carry, so the soldiers kicked them and let them sit down, then they beat them up and left them behind. I got malaria and asked for water when we were climbing mountains. They refused to give me water and I cried. I couldn’t help crying all the time. I wanted to unload my burden but they wouldn’t allow me. I needed water, but they wouldn’t let me have any.” “PORTER TESTIMONIES: KAWMOORA REGION,” KHRG, December 1992. The killing of wounded prisoners or combatants in conflict is a grave breach of the Geneva Convention, see 3.2: “The wounded and sick shall be collected and cared for.” “Geneva Convention relative to the Treatment of Prisoners of War: 75 U.N.T.S. 135,” International Committee of the Red Cross (ICRC), October 1950.
 This word has been correctly amended to ‘lucky’ from ‘luckily’ in the original published report.
 “The health situation for the internally displaced villagers is very serious. There is no medicine in the Ywa Bone villages and they are completely dependent on traditional medicines made from roots and leaves. Without letters of recommendation it is impossible to send people to Kler Lahor Toungoo for treatment. Twenty displaced people from Ha Toh Per village died from diarrhoea in 1999, simply due to a lack of basic medicines.” “PEACE VILLAGES AND HIDING VILLAGES: Roads, Relocations, and the Campaign for Control in Toungoo District,”KHRG, October 2000; see also “ABUSES AND RELOCATIONS IN PA’AN DISTRICT,” KHRG, August 1997; “Papun and Nyaunglebin Districts, Karen State: Internally displaced villagers cornered by 40 SPDC Battalions; Food shortages, disease, killings and life on the run,” KHRG, April 2001.
 “Dooplaya Interview: Saw B---, March 2015,” KHRG, November 2016; see also “Nyaunglebin Situation Update: Mone Township, November 2013 to January 2014,” KHRG, July 2014.
 “Papun Situation Update: Northern Lu Thaw Township, March to June 2012,” KHRG, September 2012; see also “Nyaunglebin Situation Update: Mone Township, November 2013 to January 2014,” KHRG, July 2014; “Toungoo Interview: Naw A---, January 2015,” KHRG, July 2015.
 Source #168.
 Source #94.
 “Toungoo Situation Update: Thandaunggyi Township, April to June 2014,” KHRG December 2014; see also source #11.
 “Toungoo Situation Update: Thandaunggyi Township, March to July 2015,” KHRG, March 2016.
 “Thaton Situation Update: Bilin Township, August to October 2014,” KHRG, April 2015.
 Source #50.
 Source #165.
 “Thaton Situation Update: Thaton Township, July to October 2015,” KHRG, April 2016.
 Source #163.
 Source #123.
 “The clinic was already built and the opening ceremony also was already held but until the present time the lock [on the clinic] has never opened [for the villagers]. There are also no medics or patients. The villagers were mainly talking about that clinic. A villager from Eu--- village said that the clinic looks very beautiful but you cannot use it for anything.” Source #123; see also “Toungoo Situation Update: Thandaunggyi Township, November 2015 to February 2016,” KHRG, November 2016.
 “Thaton Situation Update: Thaton Township, April 2014,” KHRG, January 2015.
 “Dooplaya Situation Update: Kyonedoe Township, January to June 2014,” KHRG, September 2014; see also
“Thaton Situation Update: Thaton Township, July to October 2015,” KHRG, April 2016; “Toungoo Situation Update: Thandaunggyi Township, November 2015 to February 2016,” KHRG, November 2016.
 For more information see Chapter 6: Development.
 KHRG has previously published reports detailing incidents of negative side-effects as a result of elephantiasis vaccine. The KHRG community member could be referring to the incident which occurred between September 9th and 13th 2013, when elephantiasis vaccine was distributed to 1144 villagers from Kawkareik Township by the Myanmar government. Some villagers who received the vaccination experienced dizziness, vomiting, itchy skin, swollen testicles, and even one case of miscarriage. For further details see, “Dooplaya Situation Update: Kyonedoe Township, September to December 2013,” KHRG, September 2014. Similar incidents occurred in other districts. See for example, “Field Report: Thaton District, September 2012 to December 2013,” KHRG, December 2015.
 “Dooplaya Situation Update: Kyonedoe and Kawkareik townships, July to November 2014,” KHRG, January 2016.
 Source #108.
 “Thaton Situation Update: Hpa-an Township, January to June 2014,” KHRG, October 2014; see also “Toungoo Photo Set: Ongoing militarisation and dam building consequences, March to April 2013,” KHRG, February 2014.
 Back Pack refers to the Back Pack Health Workers’ Team (BPHWT), an organisation that provides medical treatment for villagers in remote areas.
 “Thaton Situation Update: Thaton Township, July to October 2015,” KHRG, April 2016.
 “Toungoo district: Civilians displaced by dams, roads, and military control,” KHRG, August 2005; see also “Living conditions for displaced villagers and ongoing abuses in Tenasserim Division,” KHRG, October 2009.
 “We do not have clinics in our village but we have midwives and local health workers who know a bit about how to give treatments to sick people. We just get injections from them. If we have serious sickness or diseases, we have to go to [clinics] in Ep--- village to get medical treatment.” Source #170; see also “Toungoo Situation Update: Thandaunggyi Township, July to November 2014,” KHRG, April 2015; see also source #161.
 Source #161.
 Source #108.
 Source #43.
 Source #17.
 “Toungoo Situation Update: Thandaunggyi Township, January to February 2015,” KHRG, October 2015. KHRG has received several other reports of villagers experiencing negative side effects after taking medicine for elephantiasis provided by the Myanmar government. See for example, “Dooplaya Situation Update: Kyonedoe Township, September to December 2013,” KHRG, September 2014; as well as “Hpa-an Interview: Saw A---, May 2014,” KHRG,May 2014; see also “Hpa-an Interview: Saw U---, December 2013,” KHRG, October 2014; and “Field Report: Thaton District, September 2012 to December 2013,” KHRG, December 2014.
 “Toungoo Situation Update: Thandaunggyi Township, June to August 2016,” KHRG, March 2017.
 “Toungoo Situation Update: Thandaunggyi Township, April to June 2014,” KHRG, December 2014; “Dooplaya Situation Update: Kyonedoe Township, September to December 2013,” KHRG, September 2014.
 Source #94.
 Source #18.
 Source #163.
 Source #30; see also “Hpapun Situation Update: Bu Tho Township, February to July 2014,” KHRG, September 2014.
 Source #94; see also “Toungoo Situation Update: Thandaunggyi Township, April to June 2014,” KHRG, December 2014; and “Hpapun Situation Update: Dwe Lo Township, May to August 2016,” KHRG, January 2017.
 Source #139.
 “Thaton Situation Update: Thaton Township, July to October 2015,” KHRG, April 2016.
 Sources #30.
 “UNCERTAINTY, FEAR AND FLIGHT: The Current Human Rights Situation in Eastern Pa’an District,” KHRG, November 1998.
 For more information see Chapter 5: Looting, Extortion and Arbitrary Taxation.
 “SLORC IN KYA-IN & KAWKAREIK TOWNSHIPS,” KHRG, February 1996; “Achieving Health Equity in Contested Areas of Southeast Myanmar,” The Asia Foundation, June 2016.
 “[My most important human right] is health. I have been sick [and not accessed medical care] for around three years, so I cannot work on my farm. Therefore, I have to buy paddy for my family but I do not have money and I do not know where to find money. I am not healthy so I cannot do any job. Moreover, I cannot do anything [to improve my health] without money.” Source #168; see also “On April 13th 1997 my cousin was hurt by the SLORC [Tatmadaw] because for only oneday he’d missed goingfor labour buildingthe houses for SLORC[soldiers’]families.TheSLORChithimwitha gun on his head, above his right ear, and his head was broken. So then the SLORC sent him to the hospital, but they didn’t give any food to feed him in the hospital, and they didn’t even pay the cost of the medicine. They only paid the hospital for the first day. Now my cousin still isn’t healed yet. He said he’ll come here once he heals. His farm and his big house were already taken by the SLORC because his fields are near the SLORC camp.” “ABUSES AND RELOCATIONS IN PA’AN DISTRICT,” KHRG, August 1997.
 “Villagers risk arrest and execution to harvest their crops,” KHRG, December 2007.
 “STARVING THEM OUT: Forced Relocations, Killings and the Systematic Starvation of Villagers in Dooplaya District,” KHRG, March 2000; see also “Toungoo Situation Update: Thandaunggyi Township, April to June 2014,” KHRG, December 2014; “Toungoo Situation Update: Thandaunggyi Township, July to November 2014,” KHRG, April 2015.
 “Toungoo Situation Update: Thandaunggyi Township, July to November 2014,” KHRG, April 2015.
 “Dooplaya Situation Update: Kya In Seik Kyi Township, September 2012,” KHRG, June 2013.