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Myanmar: Reinstatement of Full Access Needed

I saw a 23-year-old woman, Minura Begum, lose her baby because she needed a doctor; I met a brilliant 15-year-old girl whose dream of becoming a doctor is collapsing because she is confined to a concentration camp; I met a 2-year-old boy, Hirol, who was starving after his mother died for lack of medical care. Myanmar tries to keep foreigners out of the Rohingya areas, but I’ve managed to get there in the last few years, and even then Rohingya were confined to concentration camps or to remote villages. Many were systematically denied medical care, and children were barred from public schools. It’s a 21st-century apartheid.

We believe it is critical that the Government allows humanitarian aid agencies to have unfettered access, to ensure people can receive medical care.

MSF is alarmed by the current lack of access to healthcare for those remaining in Rakhine. When it has full access to its clinics, MSF provides more than 11,000 primary and reproductive health care consultations per month, as well as emergency transport and assistance for patients requiring hospitalization. All these services are currently on hold, and other agencies report being unable to carry out activities in Rakhine due to lack of access.

To ensure access to medical care and to be able to provide assistance to conflict-affected people, MSF and other international humanitarian agencies must be allowed immediate and unhindered access to all areas of Rakhine State. Without this, there is a very real risk that patients will die unnecessarily.

MSF’s medical projects in other areas of Myanmar, namely Shan and Kachin states and Yangon, the Naga Self-Administered Zone, and Tanintharyi Region, continue to operate as usual. 

In Rakhine State, Myanmar, MSF usually operates mobile clinics providing primary healthcare consultations in a number of villages and displaced population camps, and organizing emergency medical referrals to Ministry of Health and Sports (MoHS) hospitals in Northern Rakhine.

We understand that this is a sensitive environment, particularly with regard to inter-communal tensions. This makes it all the more important that independent international organizations can play their role in treating those most vulnerable.

Hundreds of thousands of refugees are living in an extremely precarious situation, and all the preconditions for a public health disaster are there.

Prior to a suspension of travel authorization and a ban on international staff in the recent week, MSF provided healthcare services in Maungdaw and Buthidaung townships in Northern Rakhine.

In Central Rakhine, approximately 120,000 internally displaced people (IDPs) remain in camps where they are entirely dependent on humanitarian assistance for their survival, due to severe movement restrictions imposed on them. International staff have not been granted travel authorizations to visit the health facilities since a few days ago. 

We most likely still haven’t seen the full impact of this crisis in terms of health. There is an acute need for a massive humanitarian intervention focusing on food, clean water, shelter, and sanitation, and a solution is needed to reduce the size of these massive, congested camps.

On Monday MSF opened two fixed location health posts to offer primary health care and outpatient department services, malnutrition screening and mental health counseling among other things in makeshift settlements. Medical facilities, including MSF’s own clinics, are completely overwhelmed. Between August 30 and September 20, MSF clinics received a total of 9,602 outpatients, 3,344 emergency room patients, 427 inpatients, 225 patients with violence-related injuries, and 23 cases of sexual violence.

Conditions at the settlements are grim. 

These settlements are essentially rural slums that have been built on the side of the only two-lane road that runs through this part of the district. There are no roads in or out of the settlement, making aid delivery very difficult. The terrain is hilly and prone to landslides, and there is a complete absence of latrines. When you walk through the settlement, you have to wade through streams of dirty water and human feces.

With little potable water available, people are drinking water collected from paddy fields, puddles, or hand-dug shallow wells which are often contaminated. At MSF’s medical facility, 487 people were treated for diarrheal diseases between September 6 and 17.

We are receiving adults every day on the cusp of dying from dehydration. That’s very rare among adults, and signals that a public health emergency could be just around the corner. With very little money and chaotic, congested, and insufficient food distributions, many Rohingya are only eating one meal of plain rice per day. 

Comprehensive vaccination campaigns for measles and cholera need to be launched immediately to reduce the outbreak risk and protect the Rohingya and Bangladeshi populations. In anticipation, MSF has prepared an isolation unit medical facility to rapidly contain any suspected or identified cholera or measles cases.

One small event could lead to an outbreak that may be the tipping point between a crisis and a catastrophe.

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Myanmar: To end tearful and start stronger

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A post-op septic man, two very very sick babies on oxygen, and a five-year-old girl seizing and comatose probably as a result of meningitis. Genuinely one of the most frightening things I have ever been around.

In retrospect, one of the most dominant emotions during that whole experience was not what I expected. Fear? Yes. Concern? Check. Sympathy? Tick... But revulsion?

It took over 24 hours and three more trips to the ICU during the course of the next day to sift through that one. The revulsion was not at the fitting child itself - who would do that? But at the full frontal experience at the barefaced wrongness that is a system, a country, a world, where a child could be this sick and not have more done for it. In any western country that child would have been sedated, ventilated, monitored, have a central line, a feeding tube, a catheter, a BIS neuro monitor taped to the tiny forehead to catch low grade seizure activity...

But here, the only way for us to gauge seizure activity is to test the arms for rigidity, or lift the eyelid and look for the faint flickering movement that betrays an electrical storm going on inside the brain. I watched and learnt to stay calm, use the protocol in the book, base your fluid boluses and IV diazepam on their vital signs, monitor regularly. Too much diazepam and you depress the effort of breathing, making it shallow and ineffective. Too much and the seizure continues unchecked...

Somehow they all made it through the night. And so did I. Albeit tense, tired and slightly tearful.

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Myanmar: IDP Buthiduang

Buthiduang, where the stateless Bengali Muslims & Rohingyas struggle to survive. It is a medium-sized town south of Maungdaw. It feels incredibly remote, surrounded by mountains, dense untouched rainforests and a sleepy winding river. I like it a lot. The house for the medical field staff (me, the other doctor and two nurses) is as basic as they come. I’m still trying to work out if we have any electricity. The downstairs outdoor squat loo has me praying I don’t get diarrhea. 

The clinic manager was on leave for a few days, so I took on the role. Working with staff from different communities means that differences of opinion easily become political, and mediating these discussions was both time-consuming and stressful. Even simple tasks, such as dividing duties among the medical team to organising lunch breaks, every decision required some convuluted discussion. It is understandable that many staff members use me as a neutral listening ear, something that has also become quite common in Buthidaung. 

Stress levels are high here, and most staff have incredibly difficult living conditions. Doubling up as a clinic manager meant I really had little time to see patients this week. It was an interesting role though, and I did enjoy the power of telling people when they could go for lunch.

My first patient of the morning was a 15 day old baby with newly acquired spasms and poor feeding. I almost missed the diagnosis of neonatal tetanus, and looking back it was fairly straight forward.

The mother had a home delivery, and had used a kitchen blade to cut the cord. Easy marks on the diploma of tropical medicine exam, but it was the first time I’d been faced with it in real life, so it took me some time. The rest of the morning was spent dealing with incredibly sick patients: an obstructed labour, a severely immunocompromised pregnant lady who did not stop vomiting and had probably miscarried, dog bites, and acute watery diarrhea galore.

It was pretty busy, especially with limited equipment and only a nurse and midwife to help while a few others left for Outreach (bringing medical help on foot to remote villages). Important to remind ourselves we are doing our best. 

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