FATAL SILENCE ? Freedom of Expression and the Right to Health in Burma ARTICLE 19 July 1996 ACKNOWLEDGEMENTS This report was written by Martin Smith, a journalist and specialist writer on Burma and South East Asia. ARTICLE 19 gratefully acknowledges the support of the Open Society Institute for this publication. ARTICLE 19 would also like to acknowledge the considerable information, advice and constructive criticism supplied by very many different individuals and organisations working in the health and humanitarian fields on Burma. Such information was willingly supplied in the hope that it would increase both domestic and international understanding of the serious health problems in Burma. Under current political conditions, however, many aid workers have asked not to be identified. ©ARTICLE 19 ISBN 1 870798139 All rights reserved. No part of this publication may be photocopied, recorded or otherwise reproduced, stored in a retrieval system or transmitted in any form by any electronic or technical means without prior permission of the copyright owner and publisher. Note by the editor of this Internet version This version is a conversion to html of a Word document - in the Library at http://www.ibiblio.org/obl/docs/FATAL- SILENCE.doc - derived from a scan of the 1996 hard copy. The footnotes, which in the original were numbered from 1 to __ at the end of each chapter, are now placed at the end of the document, and number 1-207. The footnote references to earlier footnotes have been changed accordingly. In addition, where online versions exist of the documents referred to in the notes and bibliography, the web addresses are given, which was not the case in the original. Otherwise, the text follows the original. CONTENTS Abbreviations Chapter 1 Overview Chapter 2 Health Rights and Human Rights: The Experience of Burma Chapter 3 The Health System in Burma Chapter 4 Health in a Society Under Censorship Chapter 5 Political Restrictions on Medical Practitioners Chapter 6 Conflict and Humanitarian Crisis 6.1 The Backdrop of War 6.2 Refugees and the Internal Displacement of Civilians 6.3 The Health of Prisoners and Detainees Chapter 7 AIDS and Narcotics Chapter 8 Women and Health Chapter 9 The International Perspective Chapter 10 Conclusions and Recommendations Selected Bibliography “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion or social conditions” World Health Organization Constitution (Preamble) ABBREVIATIONS ABSDF All Burma Students Democratic Front AIDS acquired immune deficiency syndrome ASEAN Association of South East Asian Nations BADP Border Areas Development Programme BBC British Broadcasting Corporation/Burmese Border Consortium BPI Burma Pharmaceutical Industry BSPP Burma Socialist Programme Party CIA Central Intelligence Agency DKBO Democratic Karen Buddhist Organization HIV human immunodeficiency virus ICCPR International Covenant on Civil and Political Rights ICRC International Committee of the Red Cross IDU intravenous drug user ILO International Labour Organization IMR infant mortality rate KIO Kachin Independence Organization KNU Karen National Union KNPP Karenni National Progressive Party MMA Myanmar Medical Association MMCWA Myanmar Maternal and Child Welfare Association MNRC Mon National Relief Committee MP Member of Parliament MRC Myanmar Red Cross MSF Medecins Sans Frontieres MTA Mong Tai Army NGO non-governmental organization NLD National League for Democracy SLORC State Law and Order Restoration Council STD sexually-transmitted disease UDHR Universal Declaration of Human Rights UN United Nations UNDP United Nations Development Programme UNDCP United Nations International Drug Control Programme UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund UNPFA United Nations Population Fund US United States of America USAID United States Agency for International Development USDA Union Solidarity and Development Association UWSP United Wa State Party WHO World Health Organization Chapter 1 OVERVIEW Censorship has long concealed a multitude of grave issues in Burma (Myanmar1). After decades of governmental secrecy and isolation, Burma was dramatically thrust into world headlines during the short-lived democracy uprising in the summer of 1988. But, while international concern and pressure has since continued to mount over the country's long- standing political crisis, the health and humanitarian consequences of over 40 years of political malaise and ethnic conflict have largely been neglected. Indeed, in many parts of the country, they remain totally unaddressed. There are many elements involved in addressing the health crisis which now besets Burma's peoples. A fundamental aspect, in ARTICLE 19's view, is for the rights to freedom of expression and information, together with the right to democratic participation, to be ensured. In a context of censorship and secrecy, individuals cannot make informed decisions on important matters affecting their health. Without freedom of academic research and the ability to disseminate research findings, there can be no informed public debate. Denial of research and information also makes effective health planning and provision less likely at the national level. Without local participation, founded on freedom of expression and access to information, the health needs of many sections of society are likely to remain unaddressed. Likewise, secrecy and 1 Burma was renamed "Myanmar" by the State Law and Order Restoration Council (SLORC) government in 1989 as part of a governmental policy to change or re- transliterate many place names and titles. However, although recognized at the United Nations, the new term "Myanmar" is still rejected by most democratic and ethnic opposition parties. censorship have a negative impact on the work of international humanitarian agencies. Although not comparable to the crises in Rwanda or Somalia, modern-day Burma has one of the poorest health records and lowest standards of living in the developing world. At independence in 1948, the country was regarded as one of the most fertile and potentially prosperous lands in Asia. By the time of the democracy uprising in 1988, however, Burma had become one of the world's ten poorest nations. With an average per capita income of just US$ 250 per annum, today Burma is categorized by the United Nations (UN) as a Least Developed Country (LDC). Health statistics can be notoriously unreliable in Burma and, by selective quoting, very different pictures of the national health situation can be painted. With so little data available, health problems can be overestimated as well as underestimated. But among a plethora of urgent health issues, the following stand out as the legacies of decades of social and political neglect: — Burma currently has one of the highest rates of infant and maternal mortality in Asia; — only one third of the country has access to clean water or proper sanitation; — nearly half of all children of primary school age are malnourished; — with only one doctor for every 12,500 people, the national system of health care does not extend to even half the country; — health education is woefully inadequate, and only 25 per cent of all children complete the five basic years of primary school; — Burma is the world's largest producer of illicit opium and heroin, which has a grave health impact in both Burma and the international community at large; — HIV/AIDS is increasing at an alarming rate, with estimates of HIV-carriers increasing from near zero to 500,000 over the past six years; — Burma has generated over one million refugees or internally- displaced people as a result of civil war; — Burma has over one million inhabitants who have been compulsorily resettled by the government, whose health and living conditions are also often poor; — finally, it is treatable or preventable illnesses or conditions linked to poor socio-economic status, such as intestinal infestations, pneumonia, tuberculosis, malnutrition, malaria and complications arising from illicit abortions, which continue to be the main causes of unnecessary death and ill- suffering in the country. Not surprisingly, in view of the scale of these problems, virtually all international agencies attempting to establish operations inside Burma since 1988 have chosen health and education programmes as their first point of entry. For far too long, Burma's health and humanitarian crises have been allowed to continue, virtually unacknowledged and unreported, under a stifling blanket of governmental censorship and inaction. Indeed, so alarmed were they by the results of new field-surveys that, in 1992, officials of the United Nations Children's Fund (UNICEF) considered calling for an urgent campaign of international humanitarian relief to alleviate what they described as "Myanmar's Silent Emergency": For a long time the state of Myanmar's children was perhaps one of the country's best kept secrets. Decades of self-imposed isolation, fabricated sta- tistics and the absence of social research and jour- nalistic inquiry had created a false image of social developments.... In fact, neither the outside world nor even the authorities inside Myanmar have an accurate or complete appreciation of the very serious conditions in the social sectors.2 2 UNICEF, Possibilities for a United Nations Peace and Development Initiative for Myanmar (Draft for Consultation, 16 March 1992), 1. The UNICEF plan was While there can be little