During his recent visit to Australia, Dr Zhao Wai Soe, Myanmar’s former Health Minister in Aung San Su Kyi’s government – before the military coup in February 2021 – and the current Minister of Health and Education for the National Unity Government, spoke exclusively to Medical Forum about the health crisis in his country.
Eric Martin reports
The world watched on as doctors and nurses took the lead in the peaceful uprising and protests that occurred throughout Myanmar as a response to the 2021 coup, before the violent crackdown by the military forced ordinary Myanma to take up arms.
Caught between the two regimes, the British-trained orthopaedic surgeon Dr Soe was smuggled out of Myanmar by his relatives in Australia and he has spent the past two years raising awareness around the globe of the plight of his countrymen.
“The condition of our central health care was not good. We began reforming the system from 2011 after the partial democratisation, which started in 2008. But before that, the Myanmar healthcare situation equated to $1 per person per year and we had the second lowest healthcare ranking in the world,” Dr Soe said.
“Since 2008, we started to collaborate with the Australian College of Emergency Medicine and the Royal College of Surgeons. It was fantastic, I had a scholarship program in 2010 and it helped us to begin developing primary trauma care and emergency medicine in Myanmar.
“And then in 2016, Aung San Su Kyi and her NLD party won, bringing up expenditure and enacting reform in cooperation with all the healthcare workers, the doctors and nurses, and all the Myanmar people.
“During the first and second COVID wave in Myanmar, we had little mortality, and I believe that in Asia – and even the world – we were one of the few countries who controlled COVID exceptionally.
“It was because the democratic government, healthcare workers and the people of Myanmar were working together. Aung San Suu Kyi was leading our communication and participation with the public during the pandemic, showing people how to wash their hands and mouth.”
At the time, Dr Soe oversaw COVID control for the government, first for the Yangon region, then for the Jago region as well.
“That’s why I was very involved in phase one and wave one and two. At that time, we calculated just how much oxygen we were going to need and established a COVID control and quarantine centre.
“We had a systematic way of mitigating and then controlling COVID, even though during the pandemic Myanmar had a shortage of manpower, with only one third of the Sustainable Development Goals. But with that manpower, we were controlling COVID. You can imagine how they people were working – 24 hours a day, seven days a week.
“We had already planned, engaged, and paid for about 20 million Indian vaccines through two projects, one backed by the WHO for developing countries, and then through donations. At the time of the coup, we were maybe the fifth or sixth country in terms of the global vaccination drive.
Tragic timing
“But as the WHO pointed out, this was not the time to have a conflict, the pandemic was already challenging enough.”
Dr Soe found himself in the difficult position where his overwhelming concern for the people of Myanmar – and enabling them to be vaccinated – forced him to cooperate with the junta, juggling the world and his people’s perception of that collaboration, as well the limitations of operating within that environment.
“Before the coup, I was close to the junta, including Brigadier-General Min Aung Hlaing, and as senior Tatmadaw (military) their family were my patients. I even operated on them because I’m an orthopaedic surgeon, I performed knee replacement surgery for the generals, their wives, and their families,” he said.
“But the thing is, I know which is right and which is wrong. I also thought about what would happen if I stood with the people, what would happen if I walked with the military? Which is the best path to save the most people’s lives?”
In fact, Dr Soe’s experience was like a microcosm of the situation facing doctors and nurses across Myanmar, who suddenly found themselves forced to take sides.
“We all knew that, historically, the military’s mindset makes them very difficult to work with. And if we worked with the military, we could not get the kind of support we needed to succeed with COVID control and then healthcare,” Dr Soe said.
“We did not want to go back to 1988, and we did not want to go back to $1 per person per year.”
Doctors and healthcare workers were a rallying point for citizens, able to eloquently express their opposition to the junta and share that rationale, acting as unofficial spokespeople for community resistance.
“In Myanmar culture, there are five respected individuals and professions: the Buddha and then monks, parents, teachers and doctors,” Dr Soe said. “On day one and day two we were waiting to see what would happen, but by day three, doctors from Mandalay started a second demonstration. We couldn’t accept a coup of this kind during the pandemic.”
It was a decision that had ongoing ramifications for doctors and healthcare workers, leading to their continued persecution.
“The military were not happy with the healthcare workers and doctors and nurses who were leading the protests and the crackdown started targeting them; doctors, nurses and then ambulance staff were arrested and tortured,” he said.
“One of my university students was shot and killed, these are the human faces, the human stories behind what’s happening in Myanmar.
“Up to now, 85 doctors, nurses and medical and nursing students have been killed, as well as some 900 doctors, nurses and healthcare workers detained. Some of them are still in jail.
Committed
“About 40,000 healthcare workers, doctors, and nurses joined the CDM, or about 80% of the healthcare workforce. But, after two and a half years, some of them cannot continue because of the difficulties and the risk to their families inside the city – and those people beg you to know that working with the military is a very difficult situation they cannot overcome.
“Yet we still have 25,000 healthcare workers with the CDM, even though most have not received a salary for two and a half years.”
Throughout that time, those doctors and nurse have been in battlefield triage situations, and because of the trauma involved, Dr Soe holds deep concerns for the long-term impact on the mental health of Myanmar.
“Combat medical care is very important now with fighting all over Myanmar, everywhere there is armed struggle and revolution – the whole country is a war zone. There is a host of different war injuries, including gunshot wounds,” he said.
“These injuries need physical and mental rehabilitation. I’m very concerned about that because in Myanmar, as a Buddhist country, mental health was not that much of an issue, the suicide rate was relatively low, but now that rate is increasing because of the stress and brutality associated with the revolution.”
Dr Soe explained that to discuss healthcare in Myanmar within the context of the uprising, it was necessary to divide the country into three regions.
“One is the region under the control of the military, such as major cities, another region is a conflict area where there is an armed struggle; and the other area is under revolutionary or ethnic revolutionary organisation control. Population-wise, because of the cities, the military control is much higher,” he said.
“But within the conflict area, we have an ethnic health organisation that has been there for many years, joined by the CDM doctors and nurses. Actually, there are 4000 doctors and nurses who are working with the revolution in Enugu.
“There are 66 secondary hospitals where we can operate. Some are station hospitals with 25 beds, and some are township hospitals with 50 beds, but half of the hospitals we built during the revolutionary time – in just two and a half years.
Care on the move
“We also have 258 mobile and frontier hospitals where they are working. But delivering proper healthcare is very difficult. Hospitals in the military controlled area have problems with human resource shortages, with workers fleeing to the countryside to join the revolution.”
Dr Soe said Myanmar was an ethnically diverse country with nine major tribes and over 100 spoken dialects but has been heavily influenced by its time as a British colony, before gaining independence in 1947.
“At that time, the ethnic leaders, under the guidance of the national hero Aung San, the father of Aung San Suu Kyi, agreed to establish the future State as a federal and democratic country to reflect and fairly represent that diversity,” he said.
“But that never happened because Aung San was killed and then the Majority Bamar group took power and then there was the military coup. That’s why a federal democracy never eventuated and that is a reason why we have had civil war since – that’s more than 70 years, the longest civil war in the world.”
Each ethnic group has been fighting with the military for many years, and each one has their own, independent health organisation.
“I’m retiring age, yet I have seen only one side of the Myanmar healthcare system,” Dr Soe noted.
“Because I am from the Burmese side, the central government side, I have never seen the care they are delivering in ethnic organisations, in the Kachin, Karen and Karenni areas, or the Mon and Chin.
“But now we understand and know each other because we have been forced to work together. The military are not discriminating when it comes to ethnicity, they attack everybody equally.
“We are working and sharing with the ethnic organisations and early during the revolution we formed a collective, a COVID taskforce currently led by Dr Cynthia Mong, who is well known for her philanthropic efforts and is working in refugee camps on the Thai border with the Mayo Clinic.
“Before the coup we already had 1 million refugees in the Rohingya area, about 1.5 million refugees in the Kachin, Karen, Karenni, and some of the Rakhine areas, but now that has increased to 4 million.
Historically, Myanmar’s healthcare system was highly centralised, with training and resources concentrated in the cities, meaning that doctors from every corner of the country may have trained together. Now, they were reforging those relationships as they united against the junta.
But the challenges are enormous.
“The general secretary of ASEAN remarked on February 23 that the UN and other organisations were providing no real support for the refugees, no support for vaccination, and none for primary healthcare,” Dr Soe said.
“ASEAN also noted that humanitarian aid and immunisation programs were being weaponised by the military. For two and a half years there has been no immunisation of our children – not just for COVID, but the key vaccinations that will protect them and enable them to go through life safely.
“We even proposed to the UN to have a third party to monitor and evaluate, and to establish a humanitarian corridor, but that never eventuated.”
The price paid by the people of Myanmar for the conflict is not just the current political turmoil, the lives destroyed and the physical destruction of the nation’s infrastructure, but the potential impact of a future health crisis as the next generation comes of age without access to basic healthcare.
“Communicable disease outbreaks of polio, measles, and Japanese encephalitis, all these things could impact not only Myanmar but our neighbouring region – that’s very much a concern,” Dr Soe said.
“We had a 90-95% vaccination coverage before the pandemic, but now this is only 20-25% – that’s alarming. We have even been forced to trial a pilot project we bought from the black market, just because it was available, but it was a very small amount and not enough.
“Before the coup, we had an elected parliament and a real government, but we did not have any money. But people from the Myanmar diaspora donated and supported us, that was the way that we survived and were able to continue developing.
“But now it’s an even more challenging situation – our doctors and nurses have been working without salary for two and half years.
“On the junta’s side, the defence budget has gone up and the health budget has gone down. Similarly, when healthcare aid is sent through the military, we cannot get it.”
Dr Soe pointed out that material and moral support was critical – even now.
“Almost anyone can do that – just talking with me and giving me a chance to share about Myanmar; this is you standing with us, Australian doctors and nurses standing in solidarity with the people,” he said.
“And now we have developed a federal medical school, nursing school and a certificate program training program, Australian doctors can help with that area using technology to support the online training program.
“Then there’s also the Myanmar diaspora; the doctors from the diaspora have the details, they have people that they can contact who can get these supplies through. These are the areas where you can help us a lot.
“I’m sure we will win. We will win because we are fighting for the future against a brutal military regime, but after, we will need support – that’s when the rebuilding really starts.
“Our revolution is not like in 1988 or 1962. We are fighting not only for democracy, but also for federalism and the chance to embrace the opportunity to live together as a country.”