We interviewed 24 participants between July and December 2022 who all lived in Myanmar at the time of the interview.
Participant characteristics
Of the 24 people interviewed, 12 identified as male, eight as female, and four preferred not to answer. Their ages ranged from 23 to 45. Most were physicians (8/24, 33%) or nurses (7/24, 29%). Other HWs included dentists [2], midwives [2], public health supervisors [2], as well as a community health worker, health administrator, medical student (1 each); we did not ask about ethnicity. Demographic information about the interviewees can be found in Table 1. All HWs who reached out during the recruitment phase participated in the study and no participants stopped the interview before completion.
Thematic analysis
The responses of the interviewees can be grouped into three themes: (a) experiences of violence; (b) perspectives on HW and community impacts; and (c) resistance and response.
-
a)
Experiences of Violence.
Targeting Healthcare workers as individuals: All participants described frequently facing threats and attacks or witnessing or hearing about colleagues being targeted directly. Participants described arrests, physical assault, being shot, sexual violence, and frequent threats. In a few cases, family members were also targeted or jailed, which participants described as efforts to coerce the HWs into stopping their clandestine work or surrendering to authorities. One participant described colleagues’ experience, “My friends in [retracted town] got their houses burnt” (Participant 10). Targeted arrests of health workers were common, especially early on. One respondent described their experience trying to avoid arrest: “They came to our staff housing … to arrest CDMers. What we did at our housing was someone locked our housing from outside, and [we] pretended there was nobody inside” (Participant 20).
Several respondents noted that some colleagues disappeared after detention and were not heard from again. According to one HW who was arrested for participating in the CDM movement, “They got hit a lot, got broken hands, and head injury, and open wounds [on the] hands. They didn’t stitch the open wounds inside prison. They had to close the skin breaks (open wounds) after they had arrived at their home. They said they were still suffering from headaches due to having their head beaten inside” (Participant 1).
Sixteen interviewees mentioned physical assault and beatings from both personal experiences and secondhand knowledge. Twenty-one of the respondents mentioned HW arrests during or following a protest in the months after the coup and after providing medical care to anyone accused of being against the military regime. One HW said; “The protest group I was involved in was attacked on March 6th, 2021. They surrounded us from two opposite sides to arrest us. I got beaten by a baton. They pulled the hair of our protecting line members and beat their backs. I think they did [that] because we were Healthcare workers wearing uniforms” (Participant 24). While many civilian protestors were victims of attacks; respondents reported that HWs were specifically targeted by military forces. One HW discussed the result of this targeting, “…I was a former member of [the] University of Medicine student union. My name was on their list. Thus, I had to flee from home since March 21, 2021” (Participant 2). HWs were often involved in protests against the military regime and provided care to other protestors at great personal risk. At other times, because of the risk to their lives, they tried to support colleagues remotely but felt a great moral burden. One participant said that in one protest, “The actual bullet was passing just above my head” (Participant 15). As a result, the participant feared to go out again, stating that “Since I couldn’t go there, I had to help them by giving instructions by phone. We couldn’t go out to the streets. If we did, we would be shot dead” (Participant 15).
Firearms, using live ammunition and rubber bullets, were commonly used against HWs and protestors according to 20 respondents. One HW described their experience: “They used real bullets. I saw the bullets pierce the helmets. I even witnessed a healthcare worker-motorcyclist [being] shot in front of me. I had to remove the bullet pieces at thigh, and arms. I remember some lost hands, some lost legs…and also half of the face. One of my patients was [a] 40-year-old lady injured by SAC’s [State Administration Council] bombing” (Participant 6).
Many of the interviewees had participated in the initial phase of protest marches and were victims of crowd control weapons in that period, including sound and water cannons, and tear gas, as well as kinetic impact projectiles (rubber bullets). One participant noted of that period, “Of course, I was the victim of violence. When it was for [retracted march name], tear gas and sound bombs were shot at us. I also got them (tear gas canisters) when I was involved in protests like in [retracted] township” (Participant 1).
Seven interviewees described hearing about the use of sexual violence from their networks. “The military committed sexual violence such as handling female genitals by hand, penetrating female organs by sticks, and standing upon the male genitals with pressure by military boots” (Participant 2). Another participant described what happened to a female colleagues: “a female doctor [was] mistakenly arrested by them…[she was] also had beaten, kicked nearly to death, like lost teeth, and got bruised over her whole body, and also got sexual violence” (Participant 1).
Participants also noted surveillance, by both the police and military, and both implicit and explicit threats as methods of causing psychological distress, focused on HW involvement in the CDM movement. One HW described receiving calls and threatening messages in this way: “the police came to that clinic not wearing uniforms, took photos, and we knew that we were [being] watched” (Participant 9).
Targeting facilities and transports: Healthcare facilities and healthcare transports experienced aerial and ground assaults by the State Administration Council forces (SAC, Myanmar’s ruling military junta), especially since mid-2021. One interviewee described creating mobile clinics because the existing hospitals were not safe: “…the military bombed the temporary clinics and hospitals in [retracted location] with aircrafts. The Healthcare workers, including doctors and nurses, had to flee from it” (Participant 2). Attacks on facilities took many other forms including destruction or seizure of health centers, closure of facilities, blockades, and theft of medical equipment. Several participants said officers would enter the hospital at night to beat and arrest HWs, break oxygen machines, target patients, occupy the facility, and generally render it unusable. One participant said, “They forced [us] to close the pharmacies, and punished the people that lined [up] for drugs. They close[d] the oxygen resources by destroying them” (Participant 4). This was especially notable given that this violence was taking place in early 2021, when the COVID-19 pandemic was taking a large toll on the region. Often these various forms of violence that were perpetrated by SAC forces occurred in conjunction with each other with the ostensible goal of tightening control over the entire health sector. One participant described the severity of the control: “SAC wouldn’t let [us] carry drugs without their approval letters, healthcare service is so so poor. Even basic essential health services couldn’t be delivered…”(Participant 20). The military attacked and seized healthcare transport, particularly ambulances. One nurse described a personal experience of being detained following an attack on their ambulance.
Denial of healthcare to the community: Beyond targeting CDM-affiliated HWs, the SAC also denied healthcare to certain groups of patients, particularly those who supported the opposition movement and those from rural, ethnic areas. HW interviewees mentioned examples of this behavior, including providing COVID-19 vaccinations only to SAC supporters, punishing people for standing in line for medication, and destroying medicine or equipment. One interviewee described how the military confiscated equipment: “To carry drugs, like RDT (rapid diagnostic test) kits for malaria were blocked and taken by the military” (Participant 20). Participants reported that the SAC intentionally lowered the quality of care or denied access to healthcare for those who opposed the regime. One HW discussed their experience, “the public hospitals only accepted the people that are friendly to non-CDM. They denied others. [The] husband of my wife’s sister had pain in [his] abdomen and went to hospital, he was denied to even enter to the hospital. They tested him [for] COVID in his car. They referred him to [private hospital] since he tested positive. The hospital didn’t take care of him, nothing” (Participant 19).
-
b)
Perspectives on HW and community impacts.
The various forms of violence perpetrated against HWs led to injury, death, and other long-term impacts. Of the 24 respondents, 13 mentioned the death of HWs, non-HWs, and other protestors either as a direct result of attacks by the military (i.e. weapon use) or as a secondary result (i.e. death of patients from COVID-19 due to the confiscation of oxygen cylinders from clinics). In several cases, HWs were killed while attempting to treat patients. Injuries among HWs and other protestors were also frequently described. One HW described their memories of a protest, “I face violence at [location] protest. I felt endangered for my life. I heard gunshot sounds. I saw a girl get a superficial gunshot wound at her ear” (Participant 17).
HW impacts
The coup and subsequent violence impacted all facets of life in Myanmar for all residents. For HWs who actively opposed the SAC, these included professional, financial and personal/ family impacts. In particular, participants described both physical and psychological disabilities resulting from the violence they and their colleagues experienced. Some colleagues became permanently disabled, some lost limbs, others suffered from wounds that took months to heal, and some had psychological trauma as a result of arrests and torture. “A doctor friend of mine came out of prison after staying for five months there… and I found that they became so afraid of everything. Like not in sanity” (Participant 1).
For many HW interviewees, their involvement in the CDM movement meant losing their jobs in the healthcare field and being blacklisted. Many indicated that clinics were unable to legally hire them because of their CDM affiliation. Moreover, many CDM-affiliated HWs could no longer practice medicine in public, causing them to flee to rural areas or to practice in secret. One HW described their experience:“[I] came back to my hometown, became jobless, depressed, and most private hospitals wouldn’t accept me to hire since I am CDM. Not even NGOs. Even if they accept CDMs, they reduce allowances. I never went back to [the] hospital” (Participant 10). Several interviewees adapted to the hostile environment and continued to service their patients through online consultations and volunteering at charity clinics.
HW interviewees experienced serious financial hardship because they were forced out of or unable to work, compounded by the effect of rising inflation. The situation was particularly dire for the primary income-earners who supported their immediate and extended families. One HW stated, “I couldn’t support my home. It becomes more destitute. I couldn’t get any other jobs since I am a CDM person” (Participant 17). Another said without their income for the extended family, everyone was “worried and afraid” (Participant 5). One participant described the burden of disappointing parents and children: “I had to drop my parents’ hope. I am now struggling for my family and my children’s education. All the people that are taking part in revolution are not safe, including my family. [I am] endangering our lives” (Participant 3).
Several participants described the challenge of managing living conditions. For some, the compounded stress of violence, finances and occupational security was overwhelming. One HW stated, “It is unsure that I would be arrested or not if I go back home since I am currently in the jungle now. I couldn’t sleep well during the nights. I have to say stand-by even here, worrying when I would run away” (Participant 23). Another discussed the emotional toll: “I don’t want to think about the future… It is so disappointing. [My] future plans are totally ruined” (Participant 1). Some interviewees noted their inability to sleep, feelings of stress, and a sense of uncertainty for the future. Many relayed feelings such as “I feel insecure always, and mostly at night….Now, everything is upside down, nothing sure. I even feel like enough to stop nursing work after this” (Participant 13).
Beyond the financial hardships inflicted upon HWs and their families, several interviewees described feelings of fear and insecurity as well as the loss of many relationships due to their CDM affiliations. As one HW said, “There is a huge divide between CDM and non-CDM among close friends. They end their friendships like they don’t talk to each other. I also had some friendships ended with some teachers…I need to be aware of the environment …. it is very risky in security “ (Participant 15). As several HWs stated, the possibility existed that previous colleagues who were not part of CDM would report those who were part of the movement. One participant warned, “There is neither social safety nor personal safety since I was trying to be aware of who would stab my back. I needed to stay very cautious” (Participant 15). Another noted the sadness of losing friends, “Everyone is affected. Friendships were broken” (Participant 16).
Several participants touched on the moral injury of working in this context (the distress that results from professionals facing ethical dilemmas, such as prioritizing limited resources or witnessing suffering). On the one hand, as health workers, they had a professional duty to care for the sick. On the other hand, they felt that working under the military regime violated their obligations to the nation as citizens. A few rejected the idea of treating police or military members while others acknowledged their medical obligations to treat everyone. Similarly, they felt solidarity with other colleagues within the CDM movement while also feeling the pressure of needing employment and an income to keep their families fed. These tensions mounted over months and years, causing ongoing distress. Some HWs returned to work under the military regime while others received support from local NGOs, and some became destitute. One HW described it in this way: “The worst is being destitute… I know the coup is not fair. But I didn’t have enough courage to leave my work… it’s like having a dilemma” (Participant 19). Some HWs noted a loss of dignity and future while others reaffirmed their commitment to the cause and underscored their belief that, in the end, they will be victorious against the regime.
Most interviewees described their families as being supportive of the CDM cause, and indicated siblings or family members also joined the movement. Others, however, became estranged from family members who did not agree with their decision to be part of the movement. One HW noted, “My household members didn’t say much to me. The main thing was that I couldn’t support them anymore, as I used to do by my outside job. That’s it” (Participant 1). The tension between supporting the resistance movement and family was intense, including one who said, “We are doing CDM and my parents [are] worried whenever we are traveling. I would like to go back to [hometown] to collect my belongings, but my family didn’t allow me to do that because they are afraid that I would easily be arrested” (Participant 20).
Community and health system impacts: All HWs interviewed discussed the detrimental effects of the coup and the violence against health on the healthcare system, including the lack of medical supplies, the reduction in the quality of care, and the long-term impacts for patients and overall population health. Regarding wider societal impacts, one HW forecasted that, “All will be ruined. I mean, the healthcare system. For sure, Myanmar will be ranked as 192nd country if there are 191 countries in the world” (Participant 8). One HW described the impact of equipment shortages and the task shifting that is now required: “It is very different from now and then, in treating patients. There were many doctors and drugs around me at [the] hospital. Now, everything is limited, like medicine, and also, I have to manage myself. That’s why I am struggling in some procedures that [are] beyond my expertise” (Participant 22). Shortages in medicine and staffing forced some patients to suffer at home or only seek medical help in dire situations. “Even in-labor patients stopped going to the hospital since they knew they wouldn’t get any service from the hospital” (Participant 23). The resource scarcity resulted in more strife, “Oxygen cylinders were kidnapped, and taken since they were in high demand. Some died even though they shouldn’t have died. They were very young” (Participant 18).
Primary care was particularly affected by attacks on facilities and the flight of HWs and many areas stopped providing basic services such as routine immunizations. One participant noted, “there were …dysfunctional [outpatient] services too. Not even functional to half of the capacity before” (Participant 23). This was particularly concerning as tuberculosis (TB) has been a serious issue in the country. Another HW lamented, “…TB patients hardly got their drugs, and had to stop taking their medicine. I am very stress[ed] about those mainly. I just want drugs for them. If not, [they] will develop drug resistant TB” (Participant 13). Childhood vaccination campaigns and other preventive care services were reduced or stopped following the coup. One participant described that “Routine Immunizations like EPI (childhood vaccination programs) couldn’t be run…Areas that cannot run EPI for over a year couldn’t have any basic health service. No primary healthcare too. Not systematically [anyway]” (Participant 20).
The COVID-19 pandemic exacerbated the problems faced by the health system following the coup. One participant described that “fear of bullets is more concern[ing] than preventing COVID” (Participant 2). COVID-19 vaccination campaigns, previously conducted with some success, either no longer occurred or were confined to certain parts of the country (particularly pro-military regime hospitals). Many interviewees described excess deaths from COVID-19 due to lack of preventive vaccines as well as basic treatments including oxygen.
These service challenges were by no means homogenous across the country. Inequality between rural and urban areas became apparent following the coup to the participants, since some services were unavailable in rural villages. Several HWs explained that some military-regime run hospitals shut down while private hospitals charged high rates, effectively denying access to people who could not afford the cost, were ethnic minorities, or affiliated with the CDM movement. One HW described the decline in availability over time: “At first, [wealthier] people went to private clinics, but they eventually were full. Then, people couldn’t get service even if they could afford it” (Participant 15).
-
c)
Resistance and Response.
All HWs interviewed were involved in some form of resistance within the Civil Disobedience Movement. Many HWs stated that they attended protests against the military and junta military regime both as activists and to provide medical care for others as street medics.
Several described their CDM role as resisting the coup military-regime. They wanted to support the revolution and opposed working in a military-led health system, since it undermined health: “doing CDM doesn’t mean not willing to serve the people but being disobedient to military junta and coup. Therefore, I have no intention to go back to work during their era” (Participant 4). For some, the choice to join CDM was right and a source of pride. One HW described this sentiment: “I did CDM to destroy [the] military junta’s system. I will go back to work after the revolution has prevailed” (Participant 5).
In the context of targeted violence and the hardships of working clandestinely, HWs in Myanmar adapted to life under the regime in order to maintain their resistance efforts. Some activities, such as collaborating with non-military regime organizations, developing a community with other CDM professionals, and maintaining lines of communication via social media, supported a sense of solidarity. In some cases, local nonprofits provided financial support, protection or resources to people caring for their communities. One respondent described this mutually beneficial relationship: the “clinic was already opened before that. It is [an] NGO clinic. We just joined them as they welcomed us. We just need to contribute manpower and drugs” (Participant 9). In some cases, the CDM network, local health organizations or international NGOs, and charities provided supplies such as oxygen machines, or medications that facilitated basic medical care. In exchange, HWs were housed by local village people, “I am now fed by village people around here and the PDF (the armed forces of the National Unity Government)” (Participant 4). One HW expressed their gratitude: “I need to say thank you…I am very grateful to the people that came here to provide food for us taking [a] hard and long journey” (Participant 3). A few participants described staying within the village as safer than living in a medical compound where they felt more vulnerable to arrest or attacks. According to one HW, “I had to sleep over [at] other people’s houses. After all, I asked for help to [local group] and they provided a place to live. I feel safer there” (Participant 13).
Perhaps because of the displacement, social media and internet connections were critical to maintaining links to families and communities, and as a way of spreading awareness and information despite severe restrictions on free speech and press. Many interviewees described seeing social media reports of other HWs beaten and killed by SAC forces, which they said compelled them to continue their resistance. However, they perceived social media, and Facebook especially, as a dangerous platform. While some used it as a way of understanding the sentiments and affiliations of coworkers and friends, social media fractured social circles and enabled surveillance. For example, one participant said, “Everyone is affected. Friendships were broken. Blocking in social media was obvious” (Participant 1). Another described that “A friend of mine was warranted and arrested. They checked their phone and arrested [them] because of their Facebook posts. Now they are imprisoned” (Participant 10). Private messenger groups were also regarded as a way to connect with friends and allies, share experiences, but carried a risk of being identified and arrested.
Several participants stated that they wanted others to know about the current situation in Myanmar, how they are feeling, and what people both inside and outside Myanmar could do to help. Many participants described their destitution and need for support – political, practical and financial (e.g. secure jobs and basic salary)- to achieve any meaningful protection. Others asked those inside Myanmar who have not yet joined CDM to take part in the cause. Several HWs emphasized their hopes that this study could amplify their voices and lead to tangible results, such as more charitable donations and resources to their underfunded clinics, as well as protections from military air and ground strikes. Above all, they want peace. One HW relayed this message, “Please tell the world…that [a lot of] money, medicine, medical equipment and manpower are needed in our revolution” (Participant 6).
Add Comment