Written evidence from Mr Ben Simms, Tropical Health Education Trust, and Mr Marcus Wootton, Royal College of Paediatrics and Child Health (MYA0012)

This submission was authored by Marcus Wootton (Royal College of Paediatrics and Child Health) and Ben Simms (Tropical Health and Education Trust) on behalf of some 30 UK health institutions engaged in supporting the Myanmar health community. The group includes representatives from several Medical Royal Colleges, NHS Trusts, NGOs, and academic partners as well as members of the Burmese diaspora working in the NHS with established links and partnerships to affiliate organisations in Myanmar.

The submission directly addresses:

●        How can the Government improve its response to the crisis in Myanmar? 

●        What steps should the UK be taking to support justice and redress for civilians affected by the violence?

We cite first-hand accounts from doctors and nurses working in Myanmar as well as referenced academic articles and multi-source media reporting. In most cases, we have chosen illustrative examples and can provide further evidence on request, either in writing or in person. 

We present this evidence and our expert assessment of the impact on health to provide a unique perspective on the devastating effects of the coup.

We also outline the work being undertaken by UK organisations to support our colleagues in Myanmar, work the UK Government must continue to recognise and support through UK ODA.

Part 1: Summary

Q: How can the Government improve its response to the crisis in Myanmar? How can it coordinate more effectively with international allies to influence a peaceful resolution to the crisis?

1. The crisis in Myanmar, and the collapse of its health system, threatens a humanitarian catastrophe that will extend far beyond the country’s borders and could, during the pandemic, represent a threat to regional and global health security.

2. Whilst an acute global health threat comes from an unchallenged rise in COVID-19 infection[1], across Myanmar we also see a broader deterioration of health outcomes arising from violent action by the armed forces[2].

3. Health is a vital component of any wider strategy the UK Government and international community implement in Myanmar. Such a strategy should strive to protect healthcare workers, support effective COVID-19 treatment and control programmes and the operation of viable health services independent of military intimidation.

4. Having supported the development of the health system, as part of a wider, rights-based approach, the UK government has been heavily invested in support for Myanmar for many years. The coup threatens to undo much of this work.

5. The UK has championed the rights of populations to decide who governs them. Through its membership of key multilateral organisations, the UK has defended human rights and worked to enshrine them in international convention and law. The Myanmar coup represents a direct threat to those values and the implications of inaction would extend globally[3].

6. Civic society organisations represent a vital counterbalance to the Junta. UK health organisations, represented in this submission, have led the world in supporting our affiliate organisations and clinicians in Myanmar for many years. This support has been challenged but remains active and viable despite the coup.

7. British clinicians and organisations have led the international medical response in rapidly developing technical support to Myanmar’s health workers, building on long-standing Health Partnerships which connect the UK and Myanmar health community. We must act now in ways that anticipate a return of democracy by maintaining these strong ties between the UK and Myanmar health community.

8. Health Partnerships were praised by the FCDO as recently as 8th March 2021, in response to a letter submitted to the Foreign Secretary by the Presidents of several Royal Colleges and medical charities.

“The collaborative partnerships that you have established are a proven model for driving progress in global health by both building the capacity of health workforces in countries like Myanmar and bringing new skills and knowledge back to the NHS… the UK Partnerships for Health Systems programme will not be affected by the above-mentioned suspension [of UK Aid to Myanmar]. We are content with the actions THET are taking to ensure the programme does not direct any support to the military regime.”

9. However, at the time of writing, all UK Aid support for such activity has been cancelled. This includes a £7m UK Health Partnership Fund for Myanmar, c. £2m funding allocated as part of the cancelled UK Partnerships for Health Systems programme, as well as numerous smaller grants.
10. Concern about this loss of funding was raised in a letter written to the Prime Minister by Lord Crisp and Dan Poulter MP, co-Chairs of the APPG Global Health, following an APPG meeting on April 26th which was addressed by Professor Zaw Wai Soe, Minister of Health in the National Unity Government. At the time of writing, there is no clarity about whether UK Aid will be made available to support these health interventions.
11. The FCDO must make clear its intentions concerning financial support for initiatives that assist health workers and services in Myanmar as part of its broader strategy to respond to the crisis.

Q: What steps should the UK be taking to support justice and redress for civilians affected by the violence?

12. There is prima facie evidence of the intimidation, arrest and, in some cases, murder of healthcare workers by the Burmese army. This violates international law and norms in contravention of UN Resolution 2286 which prohibits harm against healthcare workers in situations of conflict. We have been working with Amnesty International and others to document these examples of violence.
13. The UK must work through international structures to prosecute those who attack healthcare workers and others.
14. We would welcome the support of the UK Government in raising awareness of these violations of the rights of healthcare workers, anticipating justice and redress.
15. The UK should continue to support organisations that partner and develop Burmese civic society including the Medical Associations.

16. The UK government has, so far, remained muted on the importance of the Burmese people to communicate freely with the outside world. The right of Burmese people to access the internet should be supported and protected. Through this route, we can offer significant clinical support to our partner organisations.

Part 2: Impact on health in Myanmar

17. The turmoil that followed the coup of 1st February 2021 has served to exacerbate the underlying health system weaknesses and threatens to unravel the progress that has been made in recent years.

18. The reasons for worsening health outcomes are complex. Many doctors and nurses have refused to work as part of the wider "Civil Disobedience Movement" (CDM).  There is also substantial evidence of sustained army interference in the delivery of healthcare, the arbitrary arrest of healthcare workers and deliberate fragmentation of the health system. The effects of this are being seen in health outcomes:

• The deterioration in the provision of healthcare and aligned COVID surveillance systems resulting in an acceleration in cases with implications in terms of spread and possible variants across the region and the world. 

• The closure of hospitals leading to increased avoidable deaths. This is likely to have disproportionally affected the elderly, expectant mothers and children.

• The widespread closure of the government hospital sector has meant that trauma care has been negatively impacted for all patients, including victims of the army crackdown. We know that many trauma patients have received substandard care in small ‘primary care’ health centres, which are woefully ill-equipped to deal with complex trauma. Many cannot offer appropriate surgery and inpatient care.

• Medical care is being provided largely in an outpatient capacity through ‘pop-up’ and private clinics, although threats from the army have made this type of activity illegal and clinicians liable to arrest.

Thanks to the convening power of THET we have been able to come together as a health community to utilise our expertise and contacts to offer support across the Myanmar health community in the areas of clinical quality and education including:

19. Guideline support

●        We have developed a low bandwidth website with simple clinical guidelines for common conditions. Over 1000 active users achieved in the past few weeks. https://www.myanmarclinicalguidance.com/

20. Specialist advice

●        We have been offering zoom calls with UK-based Burmese speaking clinical specialists which are open to any doctor or nurse working in Myanmar who wants advice. Within this, we are also offering mental health first aid support for the clinicians.

●        The deliberate internet flow restrictions mean it is very hard currently for clinicians to access this service. We can see them try to log onto the call before it quickly falls away again. Before the coup, our online events would often have more than 100 participants.

21. Supporting trauma care

●        Aside from trying to maintain the health system, our colleagues are also having to deal with a huge increase in cases of trauma.

●        Many doctors and nurses have never dealt with gunshot wounds and trauma on this scale. We have worked with colleagues at the University of Southampton Hospital and Cambridge University Hospital to record social media-friendly clinical videos to support care.

22. Clinical lectures

●        The existing partnership between the charity World Extreme Medicine and General Practitioners in Myanmar has been broadened to include a wider range of topics, many of which would traditionally be dealt with in hospital settings.

Part 3: What can the UK government do?

23. The UK must lead the world in condemnation of attacks on medical staff and seek prosecution for the perpetrators through international criminal justice mechanisms.

• We have received multiple reports of armed military personnel entering hospital premises, firing guns, undertaking arrests of both staff and patients, removing equipment and intimidating staff into releasing the personal details of doctors and nurses undertaking CDM.

●        We have seen credible reports of attacks on health personal including some captured on CCTV[4].

●        We have first-hand accounts of intimidation of our clinical colleagues including, arrest warrants issued on national television[5] and arrests of leading medical figures. This includes Professor Maw Maw Oo who was detained whilst treating patients at the Yangon General Hospital emergency department[6].

●        Living under constant threat of arrest has had a detrimental effect on the mental health of doctors and nurses. One told us that they felt ‘personally threatened: they (the army) search for any doctors in the residing area, I had to hide in others homes. And also they charged a sentence for doctors who are still in CDM, at least 10 doctors per day…. every day they (the Junta) announced 10 doctors who will be charged for CDM …we can be charged with 2yr imprisonments’

●        There are reports of physical and emotional harm to detainees who have been arrested as part of the CDM[7]. This includes doctors and nurses who have been detained.

24. The UK must work internationally to support civil society in Myanmar.

• The UK has a unique position, with strong institutional links, to convene broader international support for civic organisations which present a counterbalance to the military. The cuts in UK-AID funding threaten to undermine this advantage and reduce the influence of the UK in this part of the world.

25. The UK must support the rights of Burmese people to continue dialogue with the international community.

• The Myanmar crisis tests the UK’s resolve to work to protect the fundamental human rights of individuals across the world.

• We urge the UK to show leadership in this area in a country where it has, for decades, been heavily invested.

• There is growing and robust evidence of human rights abuses, particularly in the case of healthcare workers and UK leadership in this area can make a tangible difference.

May 2021