This editorial in the Lancet is clear about the challenge - provide as much assistance as possible without supporting misrule or inequitable distribution. This is sound guidance in any crisis or country.

"It would be heartless to deny the people of Burma any assistance the international community can provide. But it would be equally heartless to allow aid to be manipulated so as to prolong the junta’s rule or provide preferential relief for the junta’s supporters."

"Equally heartless"? I wouldn't want to be the one to do the math on that issue. "Also heartless" requires no math.

[him] moderator

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Burma and the challenge of humanitarian assistance

Burma’s “Saff ron Revolution”, and the brutal military
crackdown which followed it, brought the world’s
attention to this closed and troubled country. The
Buddhist monks and nuns who led the movement have
called for dialogue, democracy, and human rights. But
they also called on the junta to address the initial spark of
the uprising: the fi ve-fold increase in the cost of gas, the
doubling of diesel prices, and the two-thirds increases
in petrol costs imposed by the junta on Aug 19, 2007.
Burma’s people were already in desperate straights
before these price hikes. In 2000, Burma’s health-care
system was ranked 190th out of 191 nations by WHO.1
UNICEF estimates that close to a third of children
nationwide were malnourished in 2006, real wages were
being devoured by infl ation, and HIV/AIDS, tuberculosis,
malaria, and a range of other health threats were taking
terrible tolls on ordinary Burmese.2 UNICEF reported that
Government spending on health care in Burma amounted
to US$0ท40 per citizen per year in 2005, compared
with $61 in neighbouring Thailand.2 Childhood (aged
under 5 years) mortality was 106 per 1000 livebirths
in 2006, compared with 21 per 1000 in Thailand.2 The
price increases were especially infl ammatory for two
reasons. First, they aff ected an already impoverished
majority. One estimate is that for an average worker in
Rangoon, 50–75% of daily wages would now be spent
on travel alone—and fuel-price increases immediately
raised the cost of basic commodities, including food.3,4
Second, the junta under General Than Shwe made the
energy sector one of its principal supports and one of
its show pieces, selling oil and gas reserves to Thailand,
India, China, and others. And the junta was spending
these revenues lavishly: an estimated $3ท4 billion on
arms in 2006 (mainly from China, Russia, and Ukraine),
and running costs for the so-called City of Kings, the new
capi tal Naypyidaw, costed by the International Monetary
Fund at $120–240 million a year. All that in a country
where the total national budget for HIV/AIDS in 2005
was $137 000.2

The junta’s spending seems to have been beyond
their means—and the country was thought bankrupt
by mid-summer.4 The General’s solution? Squeeze more
resources out of the people. They clearly miscalculated
how much more deprivation the people could bear.
The attacks on non-violent protestors have moved the
conscience of the world. The crackdown is not over and
it has already aff ected health. Burma’s monasteries have
long been places of refuge and pastoral care. Several of
the monasteries active in the uprising and targeted in
the crackdown were important centers for HIV/AIDS
care, support, and hospice services. These centres were
not spared: “Several monasteries in Rangoon were left
empty following raids by government security forces…
Maggin monastery in Thingangyun township, which
provides care for people with HIV and AIDS, was emptied
and locked up by the authorities”.5 In the fi rst raid on the
Maggin care centre, the Abbot and four senior monks,
two aged over 80 years, were arrested.5

Humanitarian assistance programmes, already limited
by regulations imposed by the junta in 2005 and 2006,
were further hampered.2 The World Food Program has
been running food-distribution programmes for poor
people, orphans, patients with tuberculosis and HIV/AIDS,
and others for some years. This programme ran into
diffi culty as the junta closed off distribution during the
crackdown.6 Although these limits on humanitarian
aid are likely to be short term, the needs are not. And
the restrictions im posed by the junta, which led to
the withdrawal of the Global Fund and M้decins Sans
Fronti่res, and caused the International Committee of
the Red Cross to suspend many fi eld operations, remain
barriers to providing relief for the suff ering.2 The root
cause of that suff ering, military misrule, is ultimately to
blame for Burma’s hunger. This country was once a rice
ex porting nation blessed with natural resources. Burma’s
humanitarian crisis, like Zimbabwe’s, is entirely man made.
Thus it is crucial, as calls are made for increased hu manitarian
assistance, including food and essential drugs, that
the medical and humanitarian communities stay mindful
of the cause of Burma’s impoverishment—the Generals.

There will doubtless be calls for increasing health
and humanitarian assistance eff orts in Burma in the
aftermath of the Saff ron Revolution. Some people might
call for a depoliticising of aid eff orts and for increased
direct collaboration with the junta, its Ministries, and
its affi liates. It would be heartless to deny the people
of Burma any assistance the international community
can provide. But it would be equally heartless to allow
aid to be manipulated so as to prolong the junta’s rule
or provide preferential relief for the junta’s supporters.
Burma’s people have shown again that they want
freedom and they have been willing, again, to die for
their beliefs. All due diligence must be paid, as health and
humanitarian eff orts are ramped up, that such eff orts do
not prolong the cause of the very suff ering they seek to
alleviate: the military regime, which has proven such a
threat to health, wellbeing, and prosperity.

Chris Beyrer
Center for Public Health and Human Rights, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD 21205, USA
cbeyrer@jhsph.edu

I declare that I have no confl ict of interest.

1 World Health Organization. World health report 2000. Health systems:
improving performance. 2000. http://www.who.int/whr/2000/en
(accessed Oct 18, 2007).
2 Stover E, Suwanvanichkij V, Moss A, et al. The gathering storm: infectious
diseases and human rights in Burma. July, 2007. http://www.soros.org/
initiatives/bpsai/articles_publications/publications/storm_20070628/
storm_20070709.pdf (accessed Oct 17, 2007).
3 Jagan L. Soaring petrol costs deepen woes. Bangkok Post Aug 10, 2007.
http://www.burmanet.org/news/2007/08/20/bangkok-post-soaring-petrolcosts-
deepen-woes-larry-jagan (accessed Oct 17, 2007).
4 Alternative ASEAN Network on Burma. Burma Bull August, 2007. http://
www.altsean.org/Docs/PDF%20Format/Burma%20Bulletin/August%2020
07%20Burma%20Bulletin.pdf (accessed Oct 17, 2007).
5 Paung S. They came in the night, ready to kill. Irrawaddy Mag Sept 27, 2007.
http://www.irrawaddy.org/article.php?art_id=8775 (accessed Oct 17, 2007).
6 Associated Press. Junta hampering food movement; hunger big danger,
says UN. Sept 29, 2007. http://news.aol.com/story/_a/myanmar-juntahampering-
food-movement/n20070929041209990001 (accessed
Oct 17, 2007).

www.thelancet.c

om Vol 370 October 27, 2007
http://www.thelancet.com/journals/lancet/article/PIIS0140673607616158/fulltext