Monday, November 4, 2013

Golfing With Generals In Myanmar: MSF-Holland (AZG)

Doctors Without Borders.
Whether or not international aid organisations should operate in the repressive, authoritarian state of Myanmar provokes passionate debate. On one side are many exile groups and their supporters—predominantly based in Thailand, the US and the UK—who argue that it is impossible to provide aid inside Myanmar without strengthening the military regime.

On the other side are aid organisations that have chosen to work inside the country. They argue that aid can be delivered responsibly and reach people in need of assistance without undue advantage to the junta.

The debate is acrimonious and brings out half-truths on both sides: the exile groups exaggerate the regime’s excesses and the benefits accrued from international aid, and in-country agencies, in response, downplay the constraints imposed on them by the military regime.

MSF-France Supporting KNU On Thai-Burma Border

The experience of Médecins Sans Frontières in Myanmar falls squarely within this polemic.

The French section of MSF withdrew from the country in 2006 after five years of efforts to mount an effective malaria treatment programme in conflict-affected areas bordering Thailand.

It publicly denounced “the unacceptable conditions imposed by the authorities” which, if accepted, would render MSF “nothing more than a technical service provider subject to the political priorities of the junta”.

The French section of MSF began working with refugees from the Karen ethnic group in Thailand in early 1984 and was active until the 2000s in villages and camps along the border and in running cross-border operations into territory held by the rebel Karen National Union (KNU).

MSF-Holland (AZG) Supporting Bengali-Muslims on Bangladesh-Burma Border

At the other end of the spectrum lies the Dutch section of MSF which runs the largest medical programme of any aid organisation in Myanmar. It treats twice as many AIDS patients as the government and all aid agencies combined, and runs clinics across four of the country’s states and divisions.

Somewhere in between these positions, wracked with uncertainty, sits the Swiss section of MSF. It has faced major impediments to its projects since it intervened in 1999, but chose to quietly challenge government restrictions and persevere with its medical programmes.

The common explanation—whispered in the corridors of aid offices in Yangon and throughout the MSF movement—for the Dutch section’s success operating in this authoritarian state is that “the head of MSF-H plays golf with the generals”.

Like all good rumours, it is part based on fact. Unable to secure a meeting with the regional commander to discuss opening a clinic in a mining area of Kachin State, the head of MSF-Holland visited the golf club in Myitkyina where he knew the commander to be playing, and asked for his authorisation.

The request was granted and MSF established the clinic. In the moralistic tones often employed in the aid world, particularly in MSF, this story grew into a generalised myth that the head of MSF-Holland— who stayed an unprecedented fifteen years in the same post—had special relations with certain generals and was for all intents and purposes “a collaborator”.

The person in question did little to dispel the myth, avoiding debate on activities proposed, rejecting suggestions of public advocacy construed as critical of the regime, and publicly denying the difficulties of operating in Myanmar.

Nevertheless, that “playing golf” has become a euphemism for “collaboration” is indicative of a broader difficulty all MSF sections faced adapting their principles and methods of working to the Myanmar context.

After all, playing golf is a small price to pay for good relations with a commander who determines what MSF can and cannot do for the population. It might be different were MSF asked to buy the commander golf clubs, or renew his club membership.

But rather than ana-lysing how MSF-Holland mounted this ambitious programme in such a difficult context and questioning the methods employed, all MSF sections, including the Dutch section’s headquarters in Amsterdam, preferred to stick with, and then turn a blind eye to, the fallacy of an unhealthy and privileged relationship.

This chapter explores the political choices made by the three MSF sections in response to the constraints and dilemmas they faced working in Myanmar. How could two sections of the same organisation have reached such different conclusions over the ability to work in a country? What were the compromises made and strategies pursued by each that lead to such different levels of engagement with the Myanmar people?

The Choice to Intervene

Having no official mandate to determine the types of situations to which it ought to respond, MSF freely chooses where it will and will not offer its humanitarian medical assistance.

The French section of MSF began working with refugees from the Karen ethnic group in Thailand in early 1984 and was active until the 2000s in villages and camps along the border and in running cross-border operations into territory held by the rebel Karen National Union (KNU).

Although the refugee context was highly politicised, it seemed less problematic to assist victims of the junta outside the country than from within. So when MSF-Holland requested authorisation to enter Myanmar in 1989, it faced considerable scepticism from within the MSF movement.

The Dutch section’s primary rationale for intervening was to investigate health needs in border areas beset by armed conflict, and to be a witness for the outside world of what was going on.

The Myanmar army was conducting brutal counterinsurgency campaigns in several ethnic states bordering Thailand, Laos and China, which aimed to deprive insurgents of a support base by forcing villagers to move to government-controlled settlements and razing their homes and crops. Reports of rape, forced conscription and labour, and summary executions circulated among the communities of 140,000 refugees who escaped to Thailand.

Less was known about the hardships faced in Kachin State bordering China, where the Dutch section initially wished to go. Speaking publicly about the causes of suffering constituted an important element in MSF’s desire to intervene.

Repression elsewhere in Myanmar also “qualified” the country for MSF’s attention. Northern Rakhine State is home to Muslim Rohingyas and smaller Hindu minorities who are denied citizenship, and as such are more vulnerable than most to the arbitrary abuse of power by Myanmar officials.

Harsh laws govern almost every aspect of their lives, from the age at which they may marry to whether they may travel outside their home village, with sometimes dire consequences for their ability to access medical services. Unlike the Karen and Mon in Thailand, most Rohingyas who fled state repression were not given sanctuary in a neighbouring country, but were twice pushed back from Bangladesh, once in 1978, and again in 1994–95.

They returned to similar repression and brutality from which they had fled, exacerbated for many by the seizure of land and property by the government in their absence. Both the Dutch and French sections of MSF worked with the refugees in Bangladesh and were vocal critics of the government’s refoulement to Myanmar and the complicity of the UNHCR in the process.

In addition to the border conflicts and generalised repression, the Myanmar people suffer from a state of abject poverty brought about by the incompetence and investment priorities of the junta, which are sharply skewed towards maintaining power and military might over internal and external enemies—both real and imagined.

Cargo plane carrying MSF aid landed in Rangoon.
This is especially felt in the health sector, on which a staggeringly low 0.3% of GDP is spent. Millions of people do not have access to affordable and effective healthcare, and are vulnerable to suffer and die from preventable and treatable diseases such as malaria.

Myanmar faces one of the worst HIV epidemics in Asia and among the worst TB prevalence rates in the world. Inadequate treatment is causing multidrug-resistance to TB, with repercussions that are likely to be felt well beyond Myanmar’s borders.

Thus there was no shortage of serious health problems to justify MSF’s attempts to work in Myanmar. Although the country has rarely experienced an acute emergency in which large numbers of people were at risk of imminent death (the obvious exception being in the aftermath of Cyclone Nargis in 2008), the “chronic emergency” from which its population suffers is extremely widespread.

The problem with intervening lay less in the “what to do” than the “how to do it”. How can MSF assure that in helping the victims, it does not inadvertently strengthen the hand of their oppressors?

Entering the Country

MSF-Holland (AZG).
Right from the outset, MSF-Holland faced a major hurdle in its efforts to, quite literally, get a footing in Myanmar. Its request to work there in 1989 was prompted by a small opening in the regime’s isolationist stance which, until then, had limited the presence of aid organisations to a handful of UN agencies and the ICRC.

In the wake of international condemnation of the crackdown on pro-democracy demonstrators in 1988 and the imposition of sanctions by many western governments, the regime took a few steps to improve its image, including opening the door a crack to international NGOs.

But in an early prelude to demands made after Cyclone Nargis, the military regime was prepared to accept foreign aid but no MSF personnel on its soil. This was a condition that MSF could not accept—it would be impossible to assess needs or monitor the use of aid without the presence of foreign staff. It took two years of negotiations before an international staff member was authorised to stay in the then capital, Yangon. He arrived in January 1992.

In an effort to distance itself from the activities of MSF in Thailand and Bangladesh, MSF-Holland adopted the Dutch version of its name, Artzen Zonder Grenzen (AZG) for use inside the country—a name by which it is still known today (and hereafter will be used).

MSF camps in the Delta after Cyclone Nargis.
It also entered Myanmar under the auspices of UNICEF, setting up an office in the same building and using UNICEF’s “good name” to establish its credentials.

Although the use of “AZG” continues to raise eyebrows in the MSF movement, this was a small price to pay for access if it was indeed the difference in name that shielded AZG from the scrutiny to which MSF-France was subjected when it sought permission to work in-country in 1995.

The health minister supported the French section’s request but the higher echelons of the military rejected it, allegedly due to MSF’s cross-border activities and association with the KNU.

It took a much larger opening in the regime’s attitude to the exterior before MSF-France was able to return to Myanmar in 2000. By this stage MSF-Switzerland had also opted to enter Myanmar, having undertaken an exploratory assessment in 1998 at the invitation of the Health Ministry.

At this time, international aid organisations were surfing on a wave of unprecedented—albeit relative—openness, instigated by the number three of the regime, Khin Nyunt. The junta had opened its prisons, labour camps and some border areas to the ICRC’s scrutiny, and AZG and other NGOs were expanding operations. The honeymoon was not to last.

Negotiating Humanitarian Activities

Once inside the country, all MSF sections faced constraints as to what they were allowed to do, necessitating some difficult choices and tradeoffs between competing objectives.

There were three main areas of compromise that each section made on their ideal ways of working: in their independence to choose where and with whom to work; in their ability to fully control and monitor their aid; and in their ability to speak freely about the underlying causes of health problems in the country.

Independence of Choice

The mistrustful atmosphere into which AZG landed in 1992 did not bode well for much freedom of movement or choice of target population. During the long period of negotiations to enter the country, AZG’s attention focused on the plight of Rohingyas in Rakhine State, following a government crackdown on dissent in 1991 and 1992 which provoked 250,000 to flee to Bangladesh.

But access to Rakhine State was not what the government had in mind, and in its first year AZG was directed towards providing healthcare in Shwepyithar township on the outskirts of Yangon. AZG agreed to this proposal for “strategic” reasons, as a “foot-in-the-door” through which to build relationships of trust with officials, and encourage openings in areas with more pressing needs.

AZG was soon confronted with knowledge of a more impoverished township built on paddy fields across the river from Yangon called Hlaing Thayar. In an early test of whether it could, at least at the local level, prioritise assistance to those most in need, AZG requested permission to include Hlaing Thayar in a nutritional survey planned for Shwepyithar in July 1992.

Rangoon Map: Hlaing Tharyar is at top-left corner.
In what was a promising sign of AZG’s negotiating potential, the government accepted, and high rates of malnutrition found among children helped to convince the authorities to allow AZG to assist both townships.

Yet, these townships were no ordinary suburbs of Yangon but were areas to which residents of dozens of shanty-towns were forcibly relocated after the regime burned down their homes in the wake of the 1988 student uprising.

The shanty-towns had provided a ready source of protesters to join street demonstrations, and passageways through which they could escape capture by police, and so the government wanted them destroyed and cared little for the welfare of their occupants.

Fifty thousand “squatters” were moved to Hlaing Thayar in 1989, a figure which had swelled to 164,000 by 1995.7 AZG did not fully recognise the dilemma it faced, one which is recurrent in situations of forced relocation. By providing healthcare to the displaced, AZG certainly eased their hardship. But by its presence and participation in the government-run system, AZG was tacitly condoning the government’s forced relocation policy, especially as relocations continued despite AZG’s presence.

The Dutch section did express concern at the forced relocations, raising the health implications with government interlocutors, and showing visiting donors the townships to help expose the regime’s practices.

But as I discuss later, the impact of lobbying for change within the regime and particularly through outsiders was extremely limited. Had AZG eluded government controls and forged decent relations with the population, perhaps a stronger case for its presence could be made.

In an indictment of the limits imposed, one programme review from 1996 recommended holding talks with the highest levels of the Health Department to establish whether an MSF staff member, facing an emergency at the hospital when there was no other doctor or nurse present, was permitted to save a life. “Or should s/he just note down what s/he observes and let the patient die?”

MSF-Holland (AZG) Gained Foothold in Muslim Enclave Maungdaw

AZG did not lose sight of its target population, and its persistence paid off when it was allowed to visit Rakhine State in April 1993. It was not permitted independent access, but was accompanied by Ministry of Health officials in addition to a police escort for outlying areas.

A MSF doctor treating Bengali-Muslims.
AZG wanted to work in the predominantly Muslim townships from which the highest proportion of refugees in Bangladesh had fled and to which many were returning, but it again had to compromise on its choice of location, obliged to base itself in the state capital, Sittwe.

Given that malaria was the leading pathology in Rakhine State, AZG set up a malaria control programme which included training microscopists to diagnose malaria, prevention activities and treatment. AZG also ran mobile malaria clinics in nine townships, which exposed the teams to some of the problems of discrimination and forced labour meted out to the inhabitants of the region.

But according to one project coordinator, AZG’s primary goal of advocacy on behalf of the Rohingyas soon gave way to a medical focus. “Although this time was spent travelling in Rakhine, the emphasis was very much on high quality medical and laboratory activities and very little seems to have been reported or written down about the political or advocacy aspects of Rakhine”.

It took another four years before AZG was finally permitted to establish a base in the Muslim enclave of Maungdaw, in January 1998.

An attempt to expand operations to conflict-affected populations in Kachin State ended in last-minute failure in 1995 when AZG did not present the local commander with a personal gift as another NGO had done.

But impediments on the political front during this time began to be offset by unexpected successes on the medical front, reorientating AZG’s approach from the “foot-in-the-door” confidence-building efforts to one of “medical diplomacy”—acquiring leverage through its medical expertise and operational volume.

The break-through came when AZG was pseudo-officially permitted to carry out a malaria drug-resistance study in Rakhine State with Health Ministry staff in late 1995, which showed the ineffectiveness of the national treatment protocol.

The health minister was furious when he saw the publication, but by that time AZG had received permission from lower down to change treatment in Rakhine State from chloroquine and sulphadoxine-pyrimethamine to mefloquine artesunate.

When a civilian medical doctor took over as deputy health minister in 2001, the protocol officially changed to the more effective treatment. Through “medical diplomacy” the Dutch section was also instrumental in breaking the taboo over mention of the growing AIDS epidemic in Myanmar, and received permission to start health education and condom distributions in Hlaing Thayar township.

Pushing for more, AZG started to care openly for people living with AIDS, both treating opportunistic infections and addressing the widespread stigmatisation of AIDS sufferers through social programmes.

Then in August 2003, AZG pioneered treatment of AIDS patients in Myanmar with antiretroviral drugs, challenging the prevailing dogma among health agencies that in-country capacity was too low to allow for little more than health education and social marketing of condoms.12 Within five years, AZG was providing over 10,000 patients with these life-saving drugs.

This pragmatic shift to a medical focus reorientated AZG’s target population from those affected by repression or armed conflict to those affected by deadly disease. Malaria clinics, once “alibi projects” to gain access to certain areas, were joined by sexually transmitted disease (STD), HIV and tuberculosis treatment programmes to become ends in themselves.

From the late 1990s, project areas were selected by the vulnerability of inhabitants to infectious diseases: (STD) clinics were opened in the jade-mining areas of Kachin State to reduce transmission of venereal disease, and hence HIV, among the itinerant population, sex workers and intravenous drug users.

AZG began harm reduction and needle exchange activities, and increased health education about the causes and consequences of HIV infection. Similar projects began in Shan State. With a virus rather than army brutality as the cause, together with growing concern at its spread, the regime placed fewer impediments in the way of AZG’s requests to establish clinics in new areas.

This shift proved to be a shrewd political choice that dramatically increased the number of people AZG was able to assist.

MSF-Swiss Was Forced to Go to Tanintharyi first and then Loikaw

Turning to the Swiss section of MSF (MSF-CH), it also had to compromise on its choice of location when it first entered the country in 1999.

Although it gave a medical reason—among the highest rates of drug-resistant malaria in the world—as its rationale for wanting to work in the three states of Kayin, Mon and Kayah that border Thailand, MSF-CH had to start work in the coastal region of Tanintharyi Division.

“We had to compromise from the beginning and accept to sacrifice our independence with regards to where we wanted to work”, remembers the first head of mission, Patrick Wieland. “We thought that little-by-little we would gain the confidence of the local authorities and gradually reach the border regions”. But the strategy was only partially successful.

MIS General Khin Nyunt.
We did gain some ground towards the border with malaria mobile clinics, but we were never able to put a fixed clinic where we wanted to. We pushed to get as close as we could and people would come, sometimes from up to 40 kilo-metres away, to access our clinics.

As the country continued to open under the influence of Khin Nyunt, MSF-CH obtained access to Kayah State, something no other aid organisation, including the ICRC, had managed beyond visiting the state prison. The Swiss section established a fixed clinic north of the state capital, Loikaw, in March 2004.

In the everyday frustrations and constraints of working in Myanmar, simply establishing a base was considered a major achievement in “opening humanitarian space”, even though MSF-CH was unable to reach conflict-affected areas of Kayah State where it assumed—on the basis of reports by border-based agencies—that thousands of civilians were in need of humanitarian assistance.

It had to be content that it was at least providing a primary healthcare clinic to which people displaced by the army could come and receive treatment. From that base, MSF-CH kept pressing for authorisation to move closer to areas of low-level conflict with mobile clinics and through its partnership with a local NGO, Karuna.

MSF-French Was Later Allowed Into Burma in 2001

The French section, when it started programmes in 2001, did not face the same dilemma as MSF-CH and MSF-H in having to begin operations in a different area to that which it proposed.

It began a project to improve diagnosis and treatment of malaria, first in Mon and later in Kayin State, through both fixed and mobile clinics, also pushing the limits of areas to which it was authorised to go, often by boat.

MSF made large improvements in the medical care of malaria patients in the first year: the case fatality rate among hospitalised malaria patients in Mudon halved between July 2001 and June 2002, and no malaria deaths occurred in the hospital in the second half of 2002.

Furthermore, the “foot-in-the-door” approach worked to a certain extent, with projects permitted to expand into new areas such as Ye Township and Kayin State. In the newly accessible areas, the 7,500 consultations held between April and August 2004 exceeded predictions for the entire year.

This convinced MSF of the need to continue to expand activities towards the border, eventually perhaps to link up with cross-border activities from Thailand. But the purge of Prime Minister Khin Nyunt and his entire military intelligence apparatus in October 2004 sounded the death knell for further expansion for several years.

Control and Monitoring of Aid

The second main compromise the MSF sections made in Myanmar was to relinquish control over their ability to monitor the use of aid at all times. The government periodically imposed tight restrictions on travel to project sites—sometimes affecting only foreign personnel, sometimes all staff—which hindered the supervision of MSF’s projects.

As shown above, travel restrictions had long been a feature of working in Myanmar, but these intensified after the purge of Khin Nyunt in an effort to reign in the aid agencies that had expanded operations on his authority.

Hardliners replaced more moderate ministers in the government and controls over aid organisations increased: limits on the length of time allowed outside Yangon; prior approval of all new expatriate staff; lists of national staff submitted regularly to the government; lengthy process of registration with a central and line ministry; and more frequent renegotiations of the Memorandums of Understanding (MoU).

Aid agencies were also obliged to take a government “liaison officer” with them on every field trip, which had to be organised weeks in advance.

All sections of MSF had to weigh up the effects of these rules on their ability to control and monitor the use of aid, versus what they were still able to do and might be able to do if they persevered.

Contrary to claims of some exile groups, government diversion of aid—the common fear when unable to properly monitor its use—was never of serious concern.

Unlike the government-sponsored scams seen in North Korea or Ethiopia, any theft of aid that did take place was done at the local, individual level: an area commander commandeering a boat or car for his personal use; the local Township Medical Officer stealing drugs for his private clinic; or Ministry of Health staff selling polio vaccines rather than providing them free of charge.

Although frustrating in themselves, the scale of these problems was a far cry from government-sanctioned taxation or the re-direction of aid to “worthy” groups seen elsewhere. It is the fungibility of aid that caused more discomfort than its diversion per se: all MSF programmes assume responsibilities in the health field that should be the remit of government, thereby allowing state resources to be directed elsewhere.

Many MSF staff expressed their unease at this, although less so at the macro level, since few believe that the government would allocate more to the health sector if MSF left—the callous disregard shown by the regime towards Nargis survivors in proceeding with the referendum while they buried their dead, put pay to any lingering doubts about the government’s priorities.

Rather, this dilemma was felt more acutely at the local level where MSF’s efforts to avoid collaborating with the regime resulted in the establishment of independent health structures—sometimes only metres from a government clinic—further undermining local capacity.

The increased controls over aid activities that followed the purge of Khin Nyunt in late 2004 affected each MSF section differently.

A MSF TB clinic in Lashio of Shan State.
MSFCH projects in Kayah State and Tanintharyi Division were deemed off-limits for months on end. MSF-CH persevered with the endless bureaucratic procedures now needed to get staff in-country, only to have them blocked in Yangon. Some even finished their assignment without ever having reached their project site.

The waste of money and human resources this entailed reignited long-standing debates in MSF-CH over whether it should remain in Myanmar or leave. In the end, it was the “stay” view that prevailed, carried by the argument that MSF could not abandon the 500 patients it had recently put on antiretroviral drugs.

To do so would be to sentence them to death. Hence in many ways, MSF-CH became hostage to their AIDS treatment programme, changing the parameters of what the section would and would not accept to compromise on in Myanmar.

MSF-France Leaving Burma in March 2006

MSF-France, which did not have any patients on ARV treatment, decided to the contrary. The latest wave of restrictions came just as MSF had finally negotiated a permanent base in Ye from which to expand medical coverage. The regime put a stop to it all, preventing any potential witnesses to its crackdown on insurgents and those deemed to support them. The French section withdrew in March 2006, with the programme manager explaining:

“For humanitarian organisations, the issue is to recognize when our role has been reduced to being a technical service provider of the Myanmar authorities, subject to their political agenda and no longer to the goals that we have set for ourselves as a humanitarian organisation. Speaking for the French section’s programmes, we believe that we have crossed that line. It is with great bitterness that we have had to decide to leave the country”.

But even in leaving, MSF-France made a final compromise, stifling its tendencies to rally public opinion and stoke debate about the limits of humanitarian action in such a context.

The Sound of Silence

The French section’s relatively low-key departure subscribed within the logic of self-censorship that marked the third main compromise MSF sections made in Myanmar. “Witnessing” and “speaking out” (témoignage in French) had become an important part of MSF’s action since the 1980s.

By mobilising public opinion and political players, MSF aims to pressure for change. But in Myanmar, all sections believed that any public comments construed as critical of the regime would jeopardise operations, to the detriment of hundreds of thousands of patients that MSF treats annually. The teams also worried about the safety of national staff if MSF were to incur the wrath of the regime.

For these—and several other reasons related to internal organisational changes at MSF in Paris—the French section left in a half-hearted manner. AZG and MSF-CH have seldom commented publicly on the causes of suffering and constraints to addressing it—except in relation to insufficient AIDS treatment and only then in 2008—in all their years of operation.

MSF-Holland’s Clandestine Collection of Data on Bengali-Muslims

Two MSF staffers arrested for inciting Bengali riots (2012).
Treating the symptoms of repression while unable to address the causes produced discomfort among AZG staff.

AZG had intervened in Myanmar to be a witness for the outside world, yet without much discussion or debate, had mounted a medical programme that could be jeopardised by any criticism of the regime’s policies and practices.

The obvious tension between the more advocacy-oriented “humanitarian affairs” department (HAD) in Amsterdam and the coordination team in Yangon gave rise to incoherence in programmes and objectives.

The HAD produced in-depth internal papers on the plight of the Rohingya and instructed field teams to collect and compile data on incidents, which were shared behind closed doors with donors and non-operational agencies working on these issues. But without a consistent purpose for the data collection over the long years, efforts waxed and waned.

It is difficult to discern whether, in fact, the purpose was more about improving the situation for the Rohingya or fulfilling a self-prescribed “duty” of MSF to “witness and speak out”.

The disconnect between the perspectives of Yangon and Amsterdam is well illustrated in the Myanmar policy papers from 2001 to 2009, produced at headquarters. Yangon’s bottom line was clearly determined by its medical programme: it was not going to jeopardise its ability to treat 200,000 malaria patients in Rakhine State each year. Yet Amsterdam clung to the belief that witnessing was the primary reason for which AZG should stay in Myanmar.

There might be more that AZG could do to try to ease hardships for the Rohingya if the medical and “advocacy” components of the programme were more in sync.

Documenting, compiling and reporting in private to the relevant authorities on impediments to healthcare—such as travel restrictions impeding referrals and the prohibitive cost of passing through checkpoints—could be a less threatening way to bring about change than public statements on these issues, and more effective than back-door discussions with donors.

Influencing The Generals’ Erratic Decisions

Influencing the Myanmar regime’s behaviour is notoriously difficult. Richard Horsey, former head of the International Labour Organisation’s office in Myanmar, describes the regime’s strange contradiction that works against both back-door and public pressure:

[The regime] is at once dismissive of outside criticism, but at the same time curiously sensitive about how it is perceived. It seems to genuinely believe it is acting in the national interest, and feels deeply misunderstood, and unfairly treated, by the world at large.

On the one hand, this dismissiveness limits the leverage and influence of external powers, even fellow Asian states, on the regime’s behaviour, rendering futile the efforts of aid organisations to get Myanmar’s allies to pressure for improvements. On the other hand, the regime’s sensitivity to its image provokes a backlash when it is publicly criticised.

The generals expelled the head of the UN, Charles Petrie, in October 2007 after he dared suggest in his UN Day speech that the government was not doing enough to address basic human needs.

Charles Petrie and Ban Ki-Moon
Petrie also raised the monk-led “saffron revolt” of a month earlier, saying “the concerns of the people have been clearly expressed through the recent peaceful demonstrations—it is beholden on all to listen”.

This statement came in the wake of several other public criticisms from agencies working in the country, beginning with the ICRC’s rare public denunciation of a government in June 2007,which accused Myanmar of major and repeated violations of international humanitarian law.

The ICRC condemned the use of detainees as porters for the army, and lamented the regime’s refusal to engage in dialogue or to allow the institution independent access to prisons.

A few months later, thirteen NGOs issued a joint statement calling on the government to ease restrictions on their attempts to help the poorest. Petrie’s expulsion quelled further outbursts, and the ICRC’s continued absence from prisons or border areas provides a reminder of the resistance of the regime to all outside influence and pressure.

Neither MSF section lent their support to these initiatives which publicly questioned the regime’s practices. They adopted a more discreet approach, challenging the rules through actions rather than words.

Both sections frequently work without proper authorisation, sending teams of national staff to assess the needs of the newly displaced and working for long periods without a valid MoU. They also engage with outlawed groups like sex-workers and drug users, which carries risk of imprisonment for MSF’s national staff, and work on the basis that it is better to apologise after the fact than be denied permission from the outset.

In the wake of Cyclone Nargis, for example, AZG did not await permission to send a team to the delta region. Its Bangladeshi and Chinese doctors managed to remain inconspicuous and stayed on long after all other foreigners were told to leave.

MSFCH has developed a strategy of “access by annoyance”, repeatedly requesting authorisations to travel, constantly asking for explanations when denied permission, and reiterating time and again its desire to reach those most in need.

MSF-CH also sent teams and medical supplies to the sites of street protests during the saffron revolt in 2007 and tried to help the injured, even becoming blocked inside Sule Pagoda at the centre of Yangon when the area was cordoned off by police.

Although largely symbolic in its impact—injured protesters were probably afraid of visibility if treated by foreigners so stayed away—MSF-CH felt this show of solidarity was important, especially in the absence of assistance from other organisations except the ICRC.

But for all these acts of “resistance” and the number of patients treated, it is hard not to wonder whether MSF has become too mechanical in its approach, too detached from the context—seeing people in terms of the illnesses they bear rather than who they are and what they are suffering in the larger sense.

MSF-Holland’s Shifting Priorities from Human-rights to Diseases

A TB patient getting treatment in a MSF TB clinic in Lashio.
A recent programme evaluation speaks of the Rakhine project as sclerotic: that despite early successes in changing protocols and influencing acceptance of HIV in the country, AZG has not used its sizeable weight enough to push for change, which could include easing travel restrictions on patient referrals.

Whilst it is understandable that MSF prioritises operational presence over public criticism in Myanmar when so little might be gained and so much lost by the latter, it is less so to hear what is said publicly—downplaying the constraints faced by aid organisations, and showing little solidarity with those who would rather change the system and do away with the need for international aid, than merely accept its handouts.

The polarised environment is partly to blame for the former, as any admission of difficulties is seized upon by activists and used in arguments against giving aid. But this does not justify the tone and extent of the denial.

When asked in an interview what conditions MSF-CH has to accept in order to work in Myanmar, the head of mission mentioned only the MoU, and said that this was no different to what exists in other countries: “The military junta has the right to monitor our activities, exactly as the government would do in France”.

He blamed false rumours for concerns about working conditions for NGOs and claimed that MSF knows how to work in Myanmar: “We are very conscious of the practices going on in this country. We know what tone to adopt when we want to intervene in disaster areas, but we also know [how to] denounce when things don’t work as they should”.

He ended the interview comparing the lives of the people to that of “almost all developing countries” and blamed the foreign media for “exaggerating” the poor living conditions of the Burmese.

In a similar vein, the head of AZG showed a distinct lack of interest in the fate of injured monks and other protesters during the saffron revolt of October 2007. When asked by CNN whether AZG had a moral obligation to demand access to the injured and detained, the programme manager merely said, “If they come to us or if we know where they are we will treat them like anybody else”.

Evidently surprised by this response, the interviewer asked the question again. This time the response was more elaborate:

You see, we have a very large programme. We have treated last year more than one million patients, for malaria, AIDS. These programme activities are still going on. We are working for deadly diseases. So it is very important for us to continue the treatment of these patients and this is actually where our staff is busy in these clinics serving these more than a million people.

AZG’s shift from concern for victims to concern for “diseases” was complete.

Three MSFs In Burma are working In three very different ways

What emerges from the analysis above is that the three sections of MSF pursued very different approaches towards working inside Myanmar, with varying success.

AZG (MSF-Holland) initially aimed to assist conflict-affected populations by speaking publicly about their plight, but after several years of failed attempts, greater success on the medical front, and a realisation that public advocacy is likely to prompt an end to its projects, switched its focus to the less controversial area of disease.

Given the state of public health in Myanmar and the certain death awaiting those infected with HIV, severe malaria and multidrug-resistant TB, few could argue that this was not a legitimate choice. Moreover, by establishing clinics in high-risk mining areas, AZG probably assisted many displaced by conflict who migrated to these zones.

But the downside to AZG’s approach is that it came at the cost of turning a blind eye to the larger picture. In the narrow focus and routine of the medical programmes, the context became “normal” and the unacceptable accepted, such as forced labour on the street outside a clinic or the crackdown on monks protesting in the street.

MSF-Swiss (MSF-CH), for its part, pursued a relentless quest to access victims of the regime’s brutal policies, which it assumed were found in the conflict-affected border regions. Incredible energy and resources were spent over four years trying to reach sensitive areas of Kayah State.

Yet only one year after finally succeeding, MSF-CH transferred its programmes to another NGO for lack of patients. MSF-CH had been understandably reluctant to believe the junta’s claims that few people remained in these areas, preferring to trust the population estimates given by border-based activist groups.

But these turned out to be inflated, giving greater validity to AZG’s choice to focus on areas to which the displaced might have gone, such as mining towns. As a consequence, MSF-CH is now following in the footsteps of AZG, tackling infectious diseases in its clinics and in Myanmar’s prisons.

The French section’s (MSF-France) strategy, or lack thereof, in Myanmar was the most disappointing. The decision to close operations in Myanmar inspired little debate in Paris and, unlike in contexts such as the Rwandan refugee camps, no thought was given to how MSF’s withdrawal might be used to the advantage of those aid agencies who chose to stay.

Few were even informed. MSF-France lacked the imagination and passion it has shown elsewhere to find alternative ways of reaching the population, in defiance of the authorities.

Instead of beefing up existing cross-border operations, the French ceased medical runs into Mon State and all but a small TB programme in the Thai camps. This was a far cry from MSF’s determination to continue assisting North Koreans once it had withdrawn from the country in 1998, finding innovative ways to help refugees in China in spite of Beijing’s opposition.

Furthermore, in masking its operational inertia with claims to “have been gullible to have believed humanitarian space could exist in Myanmar”, MSF-France gave fuel to those arguing that international aid to the country should stop.

Critics of aid in Myanmar are incorrect when they suggest that aid is propping up the Myanmar regime, or that it is a uniquely difficult context in which to work. Nevertheless, aid organisations make some serious compromises when working in the country, particularly in relation to whom they are permitted to assist.

Whilst MSF teams on the ground grapple with the dilemmas and difficulties they face, there seems to be little consistent discussion of parameters or benchmarks against which to judge acceptable from unacceptable compromises within any section and particularly across sections.

MSF just drifts from one compromise or victory to the next without much assessment as to what worked and what did not, or any overall plan. Both MSFCH and AZG are carrying out some remarkable work in the medical field, assisting large numbers of people.

But rather than seeing this as an end in itself, MSF and especially AZG need to rethink how they can use this influence to improve the plight of people whose essential problem is not illness per se but the repression and deprivation at its source.

The delicate challenge is to find a way to push for change without exposing patients, MSF staff and allies within the regime to punishment if falling foul of those in charge.
Dr. Fiona Terry.
(Fiona TERRY, Independent researcher on humanitarian action (Australia). Dr. Fiona Terry has spent most of the last 20 years involved in humanitarian operations in different parts of the world including Northern Iraq, Somalia, the Great Lakes region of Africa, Liberia and Sudan.

She was a research director for Médecins Sans Frontières in Paris from 2000-2003 working on North Korea, Sierra Leone and Angola, before spending three years with the International Committee of the Red Cross in Myanmar (Burma).

Fiona Terry holds a Ph.D. in international relations and political science from the Australian National University and is the author of Condemned to Repeat? The Paradox of Humanitarian Action (Cornell University Press, 2002), which won the 2006 Grawemeyer Award for Ideas Improving World Order.

More recently she has been teaching at Duke University in North Carolina, and undertaken several in-depth studies for the ICRC including on the practice of neutrality in Sudan and Afghanistan, and on the protection of health care in Afghanistan. She is currently based in Kathmandu, Nepal.)

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Is Pro-Muslim MSF-Holland (AZG) Behind the Race Troubles In Arakan?