Jim Brockbank has retired from General Practice. He continues in his role as a GP Appraiser and as an International RCGP Trainer for Myanmar. He also works with the human rights organisation The Helen Bamber Foundation.

Frontline medics in the firing line,
caring for the injured is now a crime,
shot at in the street tending broken bones,
stopped at gunpoint from treating bullet wounds.

Hospitals vandalised, equipment taken,
desecrated, in violation
of the rules, of humanity, of the law.
But don’t be mistaken, we are keeping the score.1

Ahealthcare system at breaking point.

The violation of medical neutrality in Myanmar continues and since the military coup on 1st February 2021, 97 doctors have been arrested, 10 medics have been killed, 49 hospitals have been raided, and the Covid vaccination programme has been eviscerated.2 The healthcare system is at breaking point.

The violation of medical neutrality in Myanmar continues ….. The healthcare system is at breaking point.

In addition to the challenges of delivering emergency care, chronic disease management, cancer care, maternity services and paediatric services, close neighbours Nepal, Bangladesh and India are struggling with the Covid pandemic. It is only a matter of time before Covid swarms across the borders. The 200,000 to 300,000 internally displaced people in the border regions of Myanmar, where healthcare provision is limited, are particularly at risk. Despite all this healthcare professionals continue to show considerable courage, leadership, and resilience, in providing medical cover to their communities in defiance of the military crackdown in Myanmar.

The UK healthcare community response

Health Partnerships between the UK and Myanmar, often funded by UK Aid, have flourished since 2014. Since the coup on February 1st the UK health community, including the Myanmar diaspora of medics here in the UK, have come together to support their colleagues in Myanmar. Representatives from some 30 institutions have met regularly, convened by The Tropical Health and Education Trust (THET).3

THET is a specialist global health organization that educates, trains and supports health workers through partnerships, strengthening health systems and enabling people in low and middle income countries (LMIC) to access essential healthcare. THET established its office in Yangon in 2017, working with Myanmar and UK health institutions to support the strengthening of health systems in Myanmar and is currently championing support for the healthcare community in Myanmar.

Primary Care is not alone and the role call of support convened by THET is truly interdisciplinary and includes; Emergency and Trauma Medicine, Obstetrics and Gynaecology, Paediatrics and Child Health, Oncology, Dermatology, Care of the Elderly, Anaesthesia, Nursing, Midwifery, and Public Health.

The involvement of primary care in Myanmar through the RCGP Quality Improvement project has been previously discussed in the BJGP. The team has now morphed into a support group; Myanmar-UK GP Health Action and continues to meet on zoom regularly with our GP colleagues in Myanmar.

What relevance is empathy to a healthcare system at breaking point?

You might well ask! The term empathy can be ambiguous and problems of definition clutter our understanding. At its core empathy is an act of imagination that moves us from detachment to humanistic engagement and an act of curiosity to find out what matters most. Additional features include recognition of the person(s), not ‘othering’, and connectedness that reduces the distance between us all. Attentiveness to what we are being told is another key feature of empathy. Without a story there is no meaning; facts and information do not constitute meaning. Empathy is incomplete when it does not lead to action, an attempt to help, to provide material aid. These features are woven into the fabric of empathy.4

In the first 100 days of the coup a ‘project empathy’ has emerged …. organically grown from kinships and concern for colleagues.

In the first 100 days of the coup a ‘project empathy’ has emerged, not by design but organically grown from kinships and concern for colleagues formed through a variety of healthcare projects that pre-existed Covid and the Coup. Empathy has been allowed to speak for itself and reveal itself more clearly, freed from the restrictions of definition. We know it when we see it, here it is.

Flags of Empathy

Three key statements have emerged that are effectively flags of empathy standing firm against the violence that sweeps across Myanmar and for healthcare professionals who brave such dangers to care for the sick and injured. They stand in recognition of what colleagues in Myanmar are experiencing and demonstrate attentiveness to what we are being told.

“As doctors, and representatives of medical professional organisations, we are appalled by the treatment of peaceful protestors, especially our colleagues, and the resulting impact on healthcare. Members of our organisations are currently providing support to healthcare professionals in Myanmar and the reports we have received from them and others paint a damning picture of the actions of the Myanmar security forces”. BMA Statement of Solidarity: Myanmar.5


Words matter and signatories of the full statement of solidarity for Myanmar from the BMA include not only UK professional leaders but also clinicians who have been actively involved in providing support, education, training and capacity-building in Myanmar.

“All health professionals in Myanmar should be able to deliver medical care to anyone in need of their help, without fear, intimidation, attack or arrest…………….We strongly condemn the brutal attacks by Myanmar military and police forces on healthcare workers and medical transport……. All healthcare professionals must have access to use existing emergency healthcare facilities across the country”. Tropical Health Education Trust (THET).6 This statement was developed by Myanmar-UK GP Health Action, endorsed by the Association of Royal Medical Colleges and adopted by THET.

“We are deeply troubled by the multiple reports of the targeting of health professionals including whilst they are attending to injured protestors. Many health workers have been forced into hiding and forced to treat civilians in temporary clinics…… We are concerned for the safety of all health workers – and the people they care for – and are calling on all instruments of the Myanmar government and the wider international community to ensure all nurses and health workers are able to perform their duties free from violence”. Royal College of Nursing. (RCN).7

Imagining and Curiosity.

Getting stories heard and sharing meaning informs our imagining and promotes our curiosity to find out what matters most. Healthcare is under fire in Myanmar. The images and testimonies from our colleagues connect us to what is being experienced.

“Our ambulance has been shot at twice,we just had to get out and run. Every morning I say a prayer. I write my blood group, my emergency contact number, my weight and other credentials on my forearm….. There are some patients we see, lying down on the street, who we cannot reach. The military takes them, they may die… I stay in a different place every night. I am afraid of being arrested in night raids… I am doing this for my country’s people, and because I want my children to have a bright future”.

This is only one example of the many testimonies that we are bearing witness to. The delivery of essential healthcare is being prevented. A doctor at Yangon General Hospital has witnessed the army taking away life support machines including ventilators and ECG machines, destroying computers and vandalising the facilities.

Recognition.

Digital Technology is ‘spilling the beans’ on what is happening in Myanmar and the impact on the healthcare system. It has also come to the rescue channelling discussion amongst the healthcare community in the UK, and as securely as possible, with colleagues in Myanmar. Of course connectedness isn’t simply about digital technology, through attentiveness to what we are seeing and hearing from our colleagues in Myanmar the distance between us is reduced and our imagining is carried forward to recognition of the reality of what is being experienced.

Action

It is what we do with our understanding that gives empathy its effectiveness. Four key initiatives have emerged from the UK healthcare community response.

The need for advocacy has surfaced through our conversations with Myanmar medics and resulted in significant contributions to the statements referred to. In addition images and testimonies of the violation of medical neutrality and abuse of human rights have been shared with Amnesty International. Political lobbying at all levels continues including a ‘virtual meeting’ with members of the All Party Political Group on Global Health (APPG) to provide parliamentarians with insight into how the coup is affecting health workers in Myanmar, and the UK health community response. A request for UK Government support for healthcare services in Myanmar has been made in correspondence to the Prime Minister.

Our Myanmar colleagues have asked that we communicate all that is happening to the wider world.

Our Myanmar colleagues have asked that we communicate all that is happening to the wider world through the print media, television and social networking. Several articles written or facilitated by members of the UK healthcare community have appeared in the medical press including this journal, and in the mainstream press. The BBC and Channel 4 have also represented what is happening in Myanmar. It is through storytelling that empathy can be allowed to speak for itself and we can come to a better understanding of the experiences of others.

Myanmar medics tell us they need help learning to manage the trauma and emergency care they have no prior experience of and a range of educational initiatives have been developed.
A website has been established to share clinical advice and protocols for Myanmar health workers, the site does not collect any user identifiable data.8 Videos have been developed on the management of ballistics and tear gas injuries, fractures and pain control. First Aid videos for Myanmar in Burmese have been written by UK specialists. Paediatric and Adult Guidelines have been developed and additionally virtual clinical specialist support has been available through daily zoom calls with specialists.

Medics 4 Myanmar is a webinar series developed to cover a series of topics on the care of a variety of traumatic injuries. It targets all healthcare workers on the frontline and is delivered by experts in their field with experience working in remote and hostile environments.9

Help is also needed for general healthcare, which has included the development of Covid guidelines on home management for GPs, a webinar on mental health resilience in a time of crisis, and guidance on telephone triage.

This is an impressive array of initiatives in response to the call for educational support from Myanmar colleagues.

The banking system has collapsed. The junta will identify charity accounts and take the money. Anyone found carrying significant cash will be arrested and the money taken. Funding is needed for equipment such as oxygen concentrators, to support the charity clinics and to pay doctors. A UK based charity Brighter Future Foundation, supporting education and health in Myanmar, was established in 2012.10 A fundraising group has been formed representing the organisations convened by THET to explore individual philanthropy and government funding.

These initiatives of advocacy, communication, education and funding are the framework upon which ‘project empathy’ has clambered. The activity outlined has been undertaken voluntarily and has required little or no budget, but there are constraints to this approach. Following the recent government cuts of £48million in global healthcare funding which included the £7million of funding for health partnerships in Myanmar, the framework for supporting our colleagues in Myanmar is itself fragile.

WHO and the 74th World Health Assembly

In 2021 the World Health Organisation (WHO) is calling for support and action to ensure that health and care workforces are supported, protected, motivated and equipped to deliver safe health care at all times, not only during COVID-19. This is on the agenda for the 74th World Health Assembly ( the forum through which the World Health Organization is governed) which is to be held virtually 24th May to 1st June 2021.

The recent government cuts of £48million in global healthcare funding … included the £7million of funding for health partnerships in Myanmar.

The protection and investment in health and care workers is intended to accelerate the sustainable development goals and Covid 19 recovery. This stands in stark contrast to the targeting of healthcare facilities and staff in Myanmar where violence against healthcare workers is a daily occurrence.We wait to see the outcome of the assembly and hope for action in the form of material aid.

Empathy at the frontline

As clinicians were are aware that empathy is the keystone that connects and supports not only our patients, but ourselves. We must come close enough to recognise our Myanmar colleagues fully in the tragic circumstances they find themselves in and move beyond recognition to material aid.

 

References

1.“Poem For Myanmar” https://www.youtube.com/watch?v=xQiYUiLb11I

2. Prof Zaw Wai Zoe. Webinar “Responding to the coup in Myanmar: insights from Burmese & UK healthworkers” 26 April 2021

3. THET. Partnerships For Global Health. www.thet.org

4. “Empathy On Screen, An Uncomplicating Role For The Medical Humanities.” Jim Brockbank School of Arts and Humanities, King’s College London 2012.

5. https://www.bma.org.uk/news-and-opinion/statement-of-solidarity-with-myanmar 27 April 2021.

6. THET stands with health professionals in Myanmar. 24 March 2021

7. RCN position on the ongoing situation in Myanmar. 6 May 2021

8. https://www.myanmarclinicalguidance.com/

9. https://www.facebook.com/ExtremeMedicine/videos

10. www.brighterfutureuk.org

 

All photos from James Brockbank and with the consent of the featured individuals.