The Myanmar health crisis engulfing India’s under-resourced border state
“Mizoram state is financially very poor,” says Biakthansangi, the only paediatrician at Champhai district hospital, located at the northeastern border of India. The state has long been in dire need of funds from the federal government, especially for medical assistance. But the situation escalated in February 2021 when the Myanmar military staged a bloody coup and some 30 000 refugees fled over the border to India.
Sharing the longest section of Mizoram’s porous 316 mile border with Myanmar, Champhai has received the most refugees. In February 2022, the district received 8000 refugees on a single day after gunfire was reported in the Myanmarese towns of Haimual, Rih, and Khawmawi. Authorities say that, although some refugees returned home after the violence subsided, most have stayed in camps or are living with relatives and in rented accommodation in Mizoram’s border towns and villages. They mostly get by on donations from the church and money raised by local civil society groups in the state and by charities abroad. Local authorities said that the district had 9144 refugees at the time of writing.
This has put a creaking medical system under more pressure, further complicated by the fact that India does not recognise the migrants as “‘refugees” nor is it a signatory of the international conventions on refugees.
Mizoram state government has instructed hospitals to record the native home addresses of all “refugees,” who have been provided with an identity card authorised by the local administrator.
“Our hospital doesn’t offer pro bono services for all refugees,” Biakthansangi says. “But we have helped refugees who couldn’t afford treatment, even exhausted the “poor fund” [otherwise kept aside for patients from lower socioeconomic backgrounds] donated by a few generous members in the community.”
In May, residents in Lawngtlai, a border district in southern Mizoram, protested against the transfer of four doctors to another district.1 They said that the transfers left 45 doctor vacancies in the district and just seven doctors to attend a population of 114 000.
Clinics run by non-profit organisations have come to the refugees’ aid. Zokhawthar is a small trading town in east Mizoram, with a population of 4000 residents and nearly 3000 refugees. Yet until May it only had one government medical centre with only a nurse in attendance. The centre largely gave immunisations, including for covid-19, but the influx of refugees has left it overwhelmed. Plugging the gap is Zokhawthar’s Mercy Medical Center—a free clinic run by a Canadian charity—located by the Tiau river separating India and Myanmar. A military camp stands on top of a hill across the river from the centre, the only fully operational medical centre in the town with a doctor, nurse, pharmacist, laboratory technician, and eight beds for patients from both sides of the border.
C Zomuanpuii, a general physician who has been working at the medical centre for the past three years, said that the clinic was at best a primary care centre equipped to handle milder diseases such as fever, coughs, colds, dysentery, dengue, and diarrhoea. Many patients have to be referred to Champhai and Aizawl (Mizoram’s capital city over 120 miles away, riddled with roadblocks due to landslides).
Zomuanpuii says that the clinic is in serious need of medical test kits for proper diagnosis and treatment of diseases such as scrub typhus, for which they don’t have the test kit but detect by checking the patient’s blood pressure. Another clinic in the town has at least eased the pressure: on 18 May, the Mizoram state minister for law, transport, and environment opened a new refugee clinic in Zokhawthar with funds raised by the Myanmar Refugee Relief Committee, the Chin Baptist Association of North America, and Mizo Students Union.2
Mental health need
Healthcare workers say that there is a huge gap in psychosocial response from the non-profit and medical communities.
Lalrinsangi, a 25 year old mother of two, was forced to flee with her family from Myanmar to Zokhawthar. Since Myanmar police raided their homes in September, she, her husband, mother, brother, children, and a stray cat with its own litter have been living in a 10 by 10 foot shack in a row of cramped compartments at the refugee camp, paid for with the donations of local Zokhawthar residents. Lalrinsangi showed a ringworm rash on her skin that she suspects was caused by the tap water used for bathing.
The living conditions are far from ideal, but they’re at least safe from the atrocities of the junta. “I saw an older woman in her fifties being shot dead,” she says. “My younger brother was hit on the back by the cops who used an iron rod. But they didn’t kill him.” Lalrinsangi says that the torture has left her brother (aged 20) deeply scarred. “Whenever he hears a loud sound, he thinks someone’s coming to kill him and wants to run away.” But he has no one to talk to about his trauma.
The World Health Organization’s guidelines on mental health and forced displacement say that mental healthcare must be integrated with primary healthcare to make it more accessible and affordable.3 Zomuanpuii at the Mercy clinic said that on arrival many refugees report symptoms of dizziness and appetite loss. In some cases, they can’t find any underlying pathology when tested and examined. “But we don’t have any psychiatrists to refer to in Champhai,” she said. “They have to go all the way to Aizawl.”
Lucy Lalawmpuii Sailo, a social worker with Zoram Entupaul (a Champhai based non-profit organisation run by the Catholic Church), said that they are yet to use a barefoot counsellor (mental healthcare givers working with a community at the grassroots) for psychosocial support. “We are still busy providing people with the basic needs of food and shelter before we can offer any psychological support.” Sailo told The BMJ that counselling services for the refugees were urgently needed. “The migrants don’t feel entirely secure with the host community, and they keep their distance for the fear of abuse, molestation, and discrimination,” she said.
“There’s some frustration among the refugees as they don’t have a common platform with the host community, where they could understand each other,” added Sailo. “But the refugees are totally dependent on them.”
Crisis during covid
After India’s delta variant wave subsided in October 2021, Mizoram reported one of the country’s highest rates of covid infections (17% of all tested). The death rate, however, has been thankfully low (around 1% of those who tested positive for covid-19), which health authorities credit to the close collaboration between civil society bodies, including the Young Mizo Association and village councils.
Refugees receive rapid antigen tests on arrival in the country and, based on the results, are moved to a temporary or permanent camp. A senior politician from Myanmar’s Chin state, who tested positive shortly after his arrival in Champhai last year, commended the state on its timely response to covid-19. “I was in the hospital for a month on oxygen support,” the 66 year old, who asked not be identified for security reasons, told The BMJ. “The infrastructure was good and efficient,” he says, in contrast to the hundreds of thousands of people who died in his home country, either in prison or hunting for oxygen.4 The Mizoram government has also offered covid-19 vaccines to refugees—21 357 have received a first shot, 8053 of whom have an ID.
Given the state’s barebones health infrastructure, however, public health remains precarious, and the district doesn’t have PCR testing capacity. A Myanmarese doctor, speaking under anonymity as he is part of the civil disobedience movement against the military, said that stigma was prevalent with covid-19, with only a minority of affected people reporting symptoms to the authorities. He worries that the spread of infection is worse than it seems. “During the lockdown, people were quarantined and tested, but that’s it,” he said. “The true picture never reached the state authorities.”
Sexual health stigma
The refugee camps in Mizoram are a minefield of health risks for women, given the irregular supply of sanitary products and lack of sexual health measures such as distribution of contraceptives and condoms.
Doctors at the Mercy Clinic in Zokhawthar say that they have no contraceptives available, nor can they offer any preventive measures for unwanted pregnancies. Conversations about reproductive health are limited to whispers among young women in the camp.
Sexually transmitted diseases are another concern. Mizoram already had the highest prevalence of AIDS in India, with 2.37% of its population of around one million infected, according to the National AIDS Control Organisation. The Mizoram State AIDS Control Society says that between October 1990 and September 2020, 78% of HIV cases in the state were sexually transmitted, with pregnant women making up 8.5% of the positive cases.
Provenance and peer review: Commissioned; not externally peer reviewed
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: This reporting was supported by the International Women’s Media Foundation’s Howard G Buffet Fund for Women Journalists.