The global health community must stand for health and democracy in Myanmar

On February 1 2021, the Tatmadaw, the Myanmar Military, staged an illegal and illegitimate military coup. They arrested President U Win Myint, State Counsellor Aung San Suu Kyi, and several other parliamentarians. All over the country, despite widespread despair and anger, call for anti-coup resistance have quickly gone viral, also through social media, people showing peacefully their total rejection to the coup by rallying in the streets and on the web. Violence and repression on the part of the Tatmadaw seriously increased over the days. The police shoot at the unarmed protesting crowd. According to the Assistance Association for Political Prisoners (AAPP), as of May 11, 783 people have been killed, including women and children, whilst the number of civilians and injured and those arrested is several thousand (1).

Myanmar medical doctors have led the resistance through a Civil Disobedience Movement (CDM), minimizing work in hospitals under military control, closing medicine and nursing universities, using charity and private clinics to provide emergency care to the people (2). Nonetheless, not to endanger patients, CDM health personnel are using private and charity clinics to provide medical assistance at reduced fees, collaborate with general practitioners, ensure HIV and TB services, and organize staffing ambulances and clinics in the street to provide emergency medical services in case of escalating of violence.

In a recent Lancet correspondence (3), some medical colleagues, described the tragic situation in which Myanmar’s society finds itself, and in particular the inefficiency of a health system destroyed by over 50 years of military dictatorship (4,5) that the fragile democratic government was trying to reorganize and that the recent military coup has once again put in crisis.

Some of the signatories of this letter have been collaborating for several years with the health institutions and health universities of Myanmar, with the aim of contributing to the reinforcement of the health system and supporting the complex democratic transition of the country, that the Military have now suppressed. Some of us had the chance to witness the commitment and enthusiasm with which the signatories of the already mentioned Lancet letter, were working to provide the people of Myanmar with a health system worthy of the name.

In the Lancet’s Correspondence, Dr. Zaw Wai Soe and his colleagues raised some pivotal and crucial questions concerning the international health community. Recognizing that their duty as physicians is to prioritize care for their patients, must they also do so under an illegal, undemocratic, and oppressive military system? If doctors adhere to the CDM, do not carry out their work in public structures and only deal with the most serious cases in inadequate private structures, are they failing in their duty? (3) The suspension of health services is placing millions of patients with chronic illnesses in increasingly difficult situations (6,7).

To address these issues it is necessary, in our opinion, to highlight some definitions.

Following the World Health Organization, health is a state of complete physical, mental, and social well-being and not merely the absence of infirmity or disease (8).

The definition of health is not just a theoretical issue, because it has many implications for practice, policy, health services, and health promotion (9).

Health must be considered as a continuous, iterative, and dynamic process, not as a state to be achieved (10) to grasp the complexity of this phenomenon, avoiding neglecting some dynamic and iterative aspects of health conditions.

Health must potentially be attainable for everyone in real life, in all circumstances, at any age, regardless of cultural or socioeconomic status, race or religion, (11) to avoid becoming a utopia.

As defined by Article 12 of the International Covenant on Economic, Social and Cultural Rights (12), health is a fundamental human right indispensable for the exercise of other human rights. Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity”.

Health is a human right and, as such, it must be defended like all other human rights (13) and doctors must be at the forefront to guarantee and defend it.

How is it possible to think that a doctor can guarantee and defend the right to health if the society is oppressed by a military junta breaching and violating human rights? If the health professional wants to do the good for the society in which he lives and respect his duty to guarantee the health of his patients, he cannot close his eyes and adapt his work to the inhuman conditions dictated by an army which during the over 50 years of its ruling, in addition to constantly breaching the human rights of the country, has destroyed the national health system (4,5).

As the experience of Chile shows, the results of health management in periods of military dictatorship leave a mark that makes the reorganization of the health system difficult even in subsequent decades of democracy (14).

Furthermore, the Tatmadaw is reportedly seizing hospitals in the country and opening fire therewith; because personal safety is increasingly threatened by violence on the streets, patients are reluctant to travel to refill life-sustaining medications (15).

Health-care workers’ security is under threat from state violence, resulting in additional barriers to accessing care. Doctors and nurses are being killed, injured, or arrested, hence breaching the Geneva Conventions (16). How can health personnel work under fire?

The authors of the correspondence to the Lancet call for solidarity and understanding from the global health community, urging colleagues to join a global movement for the return of peace and democracy to Myanmar.

As recently appointed as National Union Government Minister, Dr. Zaw Wai Soe wrote a message for the country, and clarifies that the matter is about justice and injustice, right and wrong, moral, and immoral. The matter, he points out, is standing for the people. This is where the ethical dilemma – prioritize care for the patients or standing against the coup and protest – finds a common ground and, possibly, an answer. This is where democracy means health, and health means democracy. They are intrinsically linked, mutually becoming one precondition of the other.

Former UN Secretary General Kofi Annan affirmed: “It is my aspiration that health will finally be seen not as a blessing to be wished for, but has a human right to be fought for” (17).

Hence, the ethical dilemma raised by the authors of the article to the Lancet (3) finds an answer. The Myanmar health professionals, the Myanmar people, are fighting for their health, for their dignity, for their right to life. The international global health community cannot look the other way. The call for protecting health, as the most basic human right of every person, is a call that concerns all of us.

We remain in solidarity with all the Myanmar colleagues engaged in the resistance to the military coup. We join the call demanding the UN and the international community to commit themselves to the creation of humanitarians’ paths to allow adequate measures to combat the Covid-19 pandemic in Myanmar. We stand in solidarity and we join the global movement protesting against injustice and calling for the return of peace and democracy in Myanmar.

This Commentary is also supported by:

• Benedetta Armocida, President of Saluteglobale.it

• Giovanna Artioli, University of Parma

• Fabrizio Bassani, Associate Director General, WHO Geneve/New York

• Per G Björnstad, Cardiologist, Oslo, Norway

• Paolo Carbognani, University of Parma

• Adriano Carotti, Bambino Gesù Children’s Hospital and Research Institute, Rome, Italy

• Alfredo Chetta, University of Parma

• Nicoletta Dentico, Director Global Health Programme, Society for International Development (SID)

• Sandro Contini, Former Senior Surgeon, Medecins sans Frontièrs

• Manuela Ernst, Berna, Switzerland

• Susana Esposito, President of WADID (World Association for Infectious Diseases. and Immunological Disorders)

• Alcindo Antônio Ferla, Universidade Federal do Rio Grande do Sul, Brasil

• Túlio Batista Franco, Universidade Federal Fluminense, Brasil; Association Rede Unida, Brasil

• Lorella Franzoni, University of Parma

• Kurt Fritzsche, University of Freiburg, Germany

• Claas Lahmann, University of Freiburg, Germany

• Paolo Lauriola, ISDE (International Society of Doctors for Environment), Italy

• Glenn Laverack, Visiting Professor University of Trento, Italy

• Franco Lori, CEO and Chairman of the Board of Virostatics

• Anne-Maria Müller, University of Freiburg, Germany

• Anna Mazzucchi, Neurologyst and Neurorehabilitator, Parma, Italy

• Pedro Melo, Universidade Católica Portuguesa, Portugal

• Pierantonio Muzzetto, President Order of Surgeons and Dentists of Parma, Italy

• Maria Augusta Nicoli, Former Manager in Public Health and Social Innovation, Bologna, Italy

• Simone Ottonello, University of Parma

• Claudia Schneyinck, University of Freiburg, Germany

• Annavittoria Sarli, University of Birmingham, UK

• Umberto Squarcia, Pediatric Cardiologist, Parma, Italy

• Stefan Schmidt, University of Freiburg, Germany

• Domenico Vito, Politecnico, Milan, Italy

• Wallis Wilde-Menozzi, Writer, USA