One could be excused for being perplexed regarding the humanitarian response after Cyclone Nargis. On the one hand, it was predicted that, in the wake of the cyclone, we would be faced with thousands of subsequent deaths from disease and malnutrition, and all would be lost unless foreign organisations were immediately present. Meanwhile, the government of Myanmar was strongly reproached for restricting the presence of outside actors. On the other hand, once permission was given, the response to basic needs on the ground was slow, both by the government and by most international actors. Even so fortunately the predicted medical catastrophe did not happen.
In retrospect, the scale of the disaster was indeed huge, with 130,000 people dead or missing. Unlike after the India Ocean tsunami of 2004, the survivors had difficulty finding refuge quickly because of the extensive flooding of the flat landscape of the Irrawaddy Delta. Needs were massive in terms of emergency food relief, water and sanitation and basic household items. At the same time, however, the coping mechanisms and resilience of the surviving population meant that aid had only a limited impact in terms of saving lives. The pertinence of the humanitarian response was more about the fast restoration of minimum living conditions and psychological and economic recovery. For instance, amongst the 23,000 medical consultations and 21,000 nutrition screenings done by Médecins Sans Frontières (MSF), by far the majority were for non-lethal diseases. Despite some areas of the Delta receiving almost no external food aid, no significant increase in acute malnutrition was observed in the first four months. The primary need identified by MSF was for the distribution of basic items to hundreds of villages scattered over the flooded plains of the Delta. Mental health needs were evident, and psychological interventions were found to be highly pertinent.
The humanitarian environment
Shortly after the cyclone hit, political and humanitarian actors in the West started to speak about many thousands of impending deaths amongst the survivors and the need to open a humanitarian corridor for victims, while at the same time engaging their own fundraising machines. A press release from one non-governmental organisation stated: With the likelihood of 100,000 or more killed in the cyclone there are all the factors for a public health catastrophe which could multiply that death toll by up to 15 times in the coming period. Political pressure on the government of Myanmar ensued, culminating in the aggressive positioning of US warships off the coast of the Delta, along with talk of putting into practice the Responsibility to Protect concept for the first time.
In the context of Myanmars frozen external relations and its internal policies of self-reliance, the objectives of this approach were apparently more political than humanitarian. Only when the short-term attention of the media and major political actors diminished, and after the US warships had left, was a dialogue possible to formally establish humanitarian access. During this period of political posturing, a handful of international humanitarian actors already present in the country had been able to access and assess some of the affected areas for the first time, establishing the large scale of basic relief that was needed. It was therefore disappointing that the official freedom given to external assistance three to four weeks after the incident was not quickly exploited, given the dire predictions of catastrophe many had made. In fact, it took another month before MSF teams began to see the arrival of the majority of actors currently present in the Delta. In the end, the assistance given on the ground, in terms of quantity, speed and coverage, was small compared to that provided to the survivors of the 2004 tsunami.
Overall, the humanitarian environment in Myanmar is highly politicised, tarnished both by the logic of sanctions and by the approach of the countrys government. Objective assessments of needs and appropriate responses are complicated by the policies of the government and the restrictions it imposes, and by the political approach of humanitarian actors. By taking a political position in the country, often in line with their government donors, international humanitarian actors further compromise their ability to conduct objective needs assessments and implement efficient programmes. Such an approach would not preclude challenging the government on the grounds of the humanitarian situation and restrictions to access. The inefficiencies of international aid evident in the Nargis response do not excuse the government of Myanmar of its responsibility to respond to the relief needs of its people. In the areas of the Delta where MSF teams were active, this response was slow compared to the scale of the disaster. Official constraints placed on international humanitarian actors in the country were still present three weeks after the disaster. This meant inadequate access during this time, and only unofficial needs assessments and limited relief were possible. One month after Nargis hit, MSF teams were still identifying some badly affected populations surviving on rainwater and immature and spoiled rice crops, with cases of dead relatives floating in the surrounding water and suspended in the trees where the cyclone had deposited them.
Health: a chronic concern
In contrast to the short-term needs of the Nargis-affected population and their stable medical situation, the general population of Myanmar is affected by chronic health issues that sadly do not reach the front page of newspapers, but nevertheless amount over time to a crisis of significant proportions. As with the Nargis cyclone, it is understandably difficult for an outsider to understand the reality of needs. According to the government, the health situation is largely satisfactory, and the limited official data available tends to back up this assertion, at least partially. By contrast, actors working outside the country, mostly on the Thai border, speak of a catastrophic situation, and likewise have data to back up most of their assertions. Unfortunately, most of the actors working inside the country, where a direct view of the situation is largely possible, tend towards self-censorship, making a clear picture of the populations health status elusive.
Despite the difficulties of collecting data in the country, some conclusions can be drawn. Even using official figures published by UN bodies with government permission, one can conclude that the health situation in Myanmar is one of the worst in South-east Asia. Of the 11 countries in the region, it has the lowest life expectancy at birth and the highest rates of neonatal and under-5 mortality (WHO, World Health Statistics 2008). It has among the highest rates of tuberculosis worldwide, with 97,000 new cases detected each year. Multi-drug resistant tuberculosis has jumped from 1.5% (1995) to 4.4% among new patients, and to 16% among previously treated patients in 2004. According to the government, HIV infects 0.7% of women in Myanmar, meaning that approximately 15,000 children will start their lives HIV-positive every year. The vast majority of people affected by late-stage AIDS have no possibility of the kind of treatment freely available in most countries today. Malaria is the largest killer: deaths from this treatable disease account for more than half of those in South-east Asia. Whatever the political context, these problems amount to a humanitarian situation requiring an urgent response.
Responsibility for the health situation of Myanmars people obviously lies first and foremost with the government of Burma, which according to World Health Organisation figures spends just 0.3% of its GDP on health, the lowest proportion of public expenditure in the world. At just $4 per person per year, this is also the lowest absolute per capita figure in the world. The lack of strategic and financial commitment to health is remarkable all the more so given the resources available.
Constraints to the humanitarian response
In addition to the scale of need and the limited government response, it is difficult and complicated for humanitarian organisations to run operations in Myanmar, due to a complex system of administrative constraints that limits humanitarian access and data collection. Mostly, this means that project activities and related resources must be planned many months in advance. It takes eight months to import medicines and at least three months to obtain a visa to enter the country. Taxes on NGOs are high; for instance, to buy a vehicle attracts a 300% tax. Some parts of the country are still off-limits to humanitarian organisations. MSF Switzerland has made six formal requests to assess areas of Kayin State, without success. It has taken many years to reach the population in Kayah State. This not because the government wants to hide atrocities along the eastern border areas of the country; rather, it stems from a fear of foreign presence among populations that may not be fully under the control of the regime. This fear is unfounded, and traps the population in a vulnerable and helpless situation.
Despite overwhelming needs and a willingness among humanitarian NGOs to respond, Myanmar receives the least amount of humanitarian aid per inhabitant ($3 per person per year, 15 times less than neighbouring Laos). Although this aid doubled in financial terms between 2000 and 2005 (from $75 million to $150m), there are still only a small number of assistance projects. The Global Fund is not present in Myanmar. Limiting structural or development assistance to the government is primarily a political choice made with the political logic of sanctions. This should not be the case for humanitarian assistance, where the needs of the people are acute. The direct and accountable delivery of assistance is possible with careful planning and well-designed projects, which can be effective and cost-efficient. The distinction between humanitarian assistance directly to the people of Myanmar and bilateral or multilateral assistance to the countrys government is important in this context. It is unfortunate that sanctions, strongly supported by the US government, are such a dominating influence on the donor response.
This situation could be defended if humanitarian assistance was impossible, and if the political approach chosen by external actors had the potential to achieve a rapid and more favourable outcome for the population. But this is not the case. Meanwhile, humanitarian assistance can be provided efficiently, under certain conditions. Even if delayed, the governments decision to open up humanitarian space after the Nargis cyclone was surprising, and an indication that all is not lost when it comes to external assistance for its people.
Without needing to be sensationalist, it is accurate to state that humanitarian and medical needs in Myanmar are critical over the medium and long term for the majority of the population, and that the gaps in both the government response and external assistance are large. Increased donor support is urgently required to alleviate Myanmars chronic humanitarian problems. The people of Myanmar cannot afford to wait for their government to respond, nor can we expect sanctions to change internal political structures or policies to positively influence the humanitarian response. This does not excuse the government of Myanmar of its responsibility to provide better services for its own people, increasing its level of funding in the health sector and related strategic imperatives. Fortunately, engagement with the government internally on medical and humanitarian issues is increasingly showing fruitful results, especially when international agencies are effective in their humanitarian actions and perceived as not having a primarily political agenda. Such engagement should not include the self-censorship that often afflicts international actors in Myanmar. A transparent and accurate reporting of the situation to the government and the international aid community can be highly constructive. Highlighting health and humanitarian issues in this way is an essential responsibility of all actors in the country.
Dr Phillip Humphris is Program Manager for Médecins Sans Frontières Switzerland. His email address is: Phillip.Humphris@geneva.msf.org.