The backpack medic programme has been featured in a film that was reviewed in the Lancet last week. The Black Zone. Do any readers know if the film is available online?
Jamie
************************
Medical care and social justice in the jungles of Myanmar
Timothy Holtz
The Lancet
12 November 2016
DOI: http://dx.doi.org/10.1016/S0140-6736(16)32144-4
The past year was the worst year for displacement since World War 2. In 2015 alone, according to the United Nations High Commissioner for Refugees, there were an estimated 12·4 million newly displaced individuals, including 8·6 million internally displaced people (IDPs) and 1·8 million refugees, quadrupling the number of newly displaced people in just 4 years. The sudden and urgent plight of persons from Syria caught up in a civil war is well known, but for more than 60 years the ethnic Kayin (Karen) in eastern Myanmar (Burma) have been enduring human rights violations, oppression, and displacement in their long struggle for human rights and autonomy. The health status of the Kayin has suffered, despite the best efforts of the Backpack Health Worker Team, the subject of Grace Baek's documentary The Black Zone.
Saw Roman is one of the people working to help the Kayin. He is a veteran backpack health worker who only sees his children twice each year due to his work in the “black zone” ethnic minority regions of eastern Myanmar. These are areas where the Myanmar military has instituted a blockade of food, medical supplies, and communication. Saw Roman has a moving story, as he is committed to his “historic duty” to serve his fellow Kayin community, despite the dangerous living and working conditions inside his home Kayin State. Halfway through the film we meet his family and his two small children whom he rarely sees—it is a poignant moment in an otherwise arresting film about life in this jungle region as a backpack medic. It's a place where stateless ethnic Kayin refugees live on the Thai–Myanmar border in the refugee camp of Mae La, some venturing as backpack medics into the eastern Myanmar jungle to supply basic health care and surgical services to Kayin IDPs inside of Myanmar.
The backpack medic programme was set up more than 15 years ago to provide basic health-care services to those still living inside Kayin State and other territories, and The Black Zone shows the dedication of the young medics with passion, and compassion. Training is provided by western non-governmental organisations and health internationalists, and they appear throughout the film providing teaching support to the young medic trainees. But these health internationalists are not the focus of the film, which rightly gives more attention to the lives of several backpack medics such as Saw Roman and Saw Livingstone, who has been a medic for over 10 years. Backpack medics have been important providers of care. It seems like the only alternative for these oppressed people—to organise themselves against health and human rights abuses by the Myanmar military.
Many ethnic Kayin from Myanmar live as IDPs within the Kayin State inside Myanmar, but tens of thousands have also lived in camps and informal settlements on the Thai side of the border for decades. Severe restrictions make it difficult for the refugees to leave the camps to study or earn a living, and the film portrays their plight as well. Thailand has also stopped registrations of new refugees. Isolated, with the possibility of repatriation, and largely dependent on humanitarian assistance, they suffer a range of social and medical problems.
Another lay medic featured in the film is Maung Maung Tinn, a Kayin refugee and self-taught painter who has worked at the Mae Tao Clinic in Thailand for 16 years. He dreams of returning to his village, which is all the more painful given he can see the mountains of Myanmar from his refugee home, driving him to tears. Even though it is located in Mae Sot, Thailand, Mae Tao Clinic serves as a safe haven. At the clinic new backpack medics can get training from health internationalists, supplies and medications can be replenished, and more specialised services can be accessed. The film rightly shows the benefits of having this clinic in this community, and its founder physician Cynthia Maung has received numerous humanitarian awards.
The film is not for the faint of heart, as landmines laid by the Myanmar military are a very real threat to those who choose to venture through Kayin territory, or for those seeking repatriation. Amputations take place throughout the film, both real footage of operations by candlelight in the jungle, and in training sessions on anaesthetised porcine “patients” at Mae Tao Clinic. Landmine survivors face difficulties in accessing health care and rehabilitation services and proper prostheses—and amputees often suffer discrimination and are considered unemployable. In The Black Zone, landmine blasts cause traumatic wounds to the extremities, chest, and face, and amputation is a necessary skill for the backpack medics to have.
The film-makers show that this is a struggle for health and social justice, and the similarities to other locales are striking. On watching this film, the brigadistas de salud (“health brigades”) come to mind, who worked in liberated zones of El Salvador and Nicaragua during the brutal civil wars of the 1980s, and provided primary care in the jungle. But there is a distinct difference in The Black Zone, as Johns Hopkins Bloomberg School of Public Health Professor Chris Beyrer points out in the film, because there is no other situation where people providing health services to IDPs are themselves stateless refugees. It's dangerous for them to go in, it's dangerous while they are there, and it's dangerous when they go out to replenish supplies.
The film shows undated footage of burning villages and crackdowns on protesters in Kayin State. The Myanmar military was brutal in their crackdown of supporters of the Kayin insurgency for autonomy in the past decades, but the situation is now evolving. As effective as the images and stories are, knowledgeable viewers waiting for a fresh angle that this film could add will be left hanging. Just over a year ago there was a nationwide ceasefire with all ethnic groups in the military zones, including the Kayin, but this is only mentioned near the end of the film. And the film's narrative does not explore the implications of Myanmar's 2015 elections, which swept the National League for Democracy (NLD) into victory, and placed NLD leader Daw Aung Sang Suu Kyi as the de-facto new head of the government as of April 6, 2016. This was a seismic shift in the history of the country, but is barely mentioned. The ground has shifted dramatically, and things are moving quickly. Foreign donors are pouring into Myanmar, including for health, and with that brings uncertainty of how much people in the ethnic states will benefit.
In the post-war struggle for health in El Salvador and Nicaragua during the 1990s, brigadistas de salud worked in health cooperatives in areas where IDPs resettled, staffing peacetime health units and primary health care clinics in former combat zones. These projects were supported by local communities and development agencies with a contingent of international health volunteers. The successful models in the region built health-care delivery systems with a strong degree of community health committee input and control based on lay health workers. After the signing of peace agreements, many of these same staff and projects were continued, using health as a reconciliation tool and a bridge to peace, although some were deconstructed by large outside donors.
In Myanmar, can health be used as a bridge to peace in the ethnic minority areas? What should be the roles of the backpack medics in a new health-care system? How can the new government best focus on the minority populations? Can the Kayin backpack medics work with the NLD and Ministry of Health to build a system in their area?
It's unlikely that there will be a formal truth and reconciliation commission on past human rights abuses during military rule, as long as there is a power sharing agreement between the Myanmar military and the NLD. Myanmar's ceasefire is tenuous but it has held. Economic sanctions are gone, but the generals remain, and military cadre in senior positions dominate the centralised ministries, including health. So far, the new government is not participatory oriented, and not rooted in communities, and there has been no serious collaboration across ethnic lines. In 2015 the Black Ribbon movement arose to protest military appointees to health posts, and to date there have been no new appointments. But there is a serious risk of undermining ethnic-led services and initiatives such as those outlined in The Black Zone, which have been built over decades.
Medics can do great work, but now the population needs front-line health workers who have resources and well equipped facilities to provide high quality community primary health care. The Burmese Health Convergence Core Group, of which the Backpack Health Worker Team is a part, has called for a decentralised, comprehensive primary health care system that puts communities first. There is a real danger—as ultimately happened in Central America—that the foundation for a truly community-based primary health care system could be scuttled by the ruling military elite, and the priorities of outside donors.
As after the Central American wars of the 1980s, health can be used as a bridge to peace for the Kayin people. But going through a top-down health system as is the constitutionally mandated case in Myanmar today—with little or no community consultation or decision making and accountability—runs the risk of undermining trust and makes achieving sustainable peace in the future all the more difficult. The Black Zone should be required viewing for those who start to work in the “gold rush” of money pouring into Myanmar to improve the health-care system now that the country is no longer regarded as an international pariah. If the nationwide ceasefire holds, the true hard work of health solidarity must begin.
The Black Zone Directed by Grace Baek. http://www.theblackzonefilm.com/
Screening at the 2016 Global Health Film Festival on Nov 11–12, 2016 at the Barbican, London, UK http://www.globalhealthfilm.org/ghff-2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32144-4/fulltext
