There is nothing quite like being woken up at 5am by the high-pitched warble of Burmese prayer pop blasted from temple speakers. What the rude start has in its favour, however, is the opportunity to wander the pre-dawn streets and watch burgundy-robed monks bend in thanks as they silently collect daily alms of steamed rice. It is a chance to witness a little of the spirit that has so gently and effectively secured Myanmar’s spot at the very pinnacle of global generosity: in 2015, Myanmar was number one in the World Giving Index.

It is humbling to learn, in a world of profit, bravado and bottom lines, that the world’s most giving country is also one of its most disadvantaged. Wracked by greed, mismanagement, civil war and a procession of historical injustices, Myanmar is more generous than runner up, USA, and a lot more generous than Australia, which came in at number six.

It’s possible that without its ubiquitous alms and donations, the Burmese community might not have weathered its past in the same way. But it has also gained from the ingenuity that comes from having so little and needing so much – in Myanmar, survival often comes hand in hand with creativity. For a population let down by non-existent, bribe-riddled civil systems, the Burmese long ago learnt to rely on their own wits to safeguard children’s futures, despite the risk to their own safety.

While Aung San Suu Kyi’s monumental November 2015 election win ushered in the beginning of the end of the crippling kleptocracy that has rung former Burma dry over 50 years, the hangover from astonishing levels of corruption, intimidation, thievery and brutality will persist: it will take decades, if not generations, for the Ayarwaddy child to find its feet.

 

SECRET FRONTLINE: Seven Mile, Yangon

Fans whir next to bare strip lights, barely cutting through the close, early evening heat in Yangon’s Seven Mile district. Leaning against a wall in the room, partly filled with stacks of printed Buddhist scripts, is a white board of elections results tallies. The indecipherable curling Burmese script cannot hide the clear winner in the neat rows of numbers.

November’s historic National Democratic Party election win is monumental to most in the country, but here at Zalattni press, the news is particularly laden. The jumbled room next door, where an antiquated printing press sits next to a newer, electric one amongst rolls of paper, dangling electricity lines and the odd wandering chicken, was a hidden frontline in the medical education of the country’s most poorly served.

In the Myanmar of military rule, the press – partly funded by the small Sydney-based charity, Myanmar Australia Conolly Foundation (MACF) – began secretly printing copies of Where There is No Doctor, a developing world medical guide designed for those who have no access to healthcare, in the Shan language.

MACF is well-versed in the effects of strangled health budgets and droughts of medical supplies and skills. According to the World Health Organisation, the state spent $37 on healthcare per capita in 2013. In Australia, the figure was $4191. But the inadequacy is only magnified for the country’s 6 million ethnic Shan people, factions of whom are engaged in civil war against the Burmese Army in a struggle for independence that has lasted for more than five decades.

Without access to any form of doctor in remote areas, the book soon became a boon, if not a lifesaver, for the rural sick and injured – not least insurgent troops, for whom the guide is a critical element of a piecemeal medical education.

The regime monitored every publication in the country, treating those who published ethnic literature unforgivingly.

Its creation was, says MACF’s Dr Joyce Conolly, an act of huge bravery. Over the 15 years that she and her husband, Sydney Hospital hand specialist Professor W Bruce Conolly, have worked in the country with their medical charity, she has watched the book go from clandestine to tolerated. Not without losses, however: the press’ owner, U Sai Nyunt Lwin, was imprisoned in 2006 for five years.

“It was a risk to ourselves,” says Dr Sai Kyaw Han, who, with editor Dr Sai Hla, oversaw the nascence of the guide in 2006.

“The government did not want to see those ethnic people working actively like this.

“Nowadays, it is not so sensitive. We just did it quietly, we didn’t do any ceremony.”

Translated into Shan by Dr Sai Pe and Sai Kong Sid, the guide and its sister version, Where Women Have No Doctor, with their clear illustrations and straightforward instructions, were able to quietly spread among the ethnic Shan population, well beyond the reach of the government’s rudimentary and chronically neglected healthcare system.

The books, printed by Sai Pe and his wife at 2am, often the only time there was electricity,  became a cog in a well-developed social network across the country.

“Civil society groups in rural areas are very active for any emergency or development works,” he explains. “The network distributes help. They can’t rely on authorities for help. People don’t expect much from the government.”

Nowadays, an online version of Where There is No Doctor is available via the Hesperian foundation, and a local update by Zalattni is due to be published this year, funding permitting. It is hoped that the book will eventually reach every one of the country’s 17,000-plus Shan speaking villages.

Many in Myanmar are waiting patiently for a smooth transition from military control. The country may be on the cusp of change, but few expect that change to come quickly – and the need for Where There is No Doctor is likely to persist for decades.

 

FORGOTTEN ISLAND: Seikkyi, Yangon

The island of Seikkyi, a short boat ride from Yangon’s frenetic riverfront, is a place of close community and wooden huts interspersed with swampland, lily pad-topped lakes and flood-prone waterways. Even in the cool season, the humidity hangs heavy in the heat, a blanket over the 10,000-plus population.

It is separated from the centre of Myanmar’s largest city by just 200 metres or so of the muddy, smooth-flowing Ayarwaddy River, but Ngazin, the island’s main village, is also one of the country’s poorest, most socially, geographically and economically disadvantaged communities.

“This is a really good example of a marginalised community,” says Peter Simmons, whose Melbourne-based charity GraceWorks and affiliate MACF has worked with Seikkyi’s residents to install a health clinic in the village, which will be completed this year.  There are two doctors on the island, one of whom is retired and one of whom is private and unfazed by charging dearly for his services.

“It’s a forgotten community. There are no services at all. Half of these people have never left the island – they can’t afford to. The island is in a timewarp, they think people across the river are wealthy.”

They are wrong, though Yangon is a city of dualities. Where there is extreme wealth, there is also acute and widespread poverty. Open sewers, no rubbish collection, slums and a desperate need for doctors, hospitals and healthcare shape a city that is, right now, in a state of monumental change. High rise buildings are beginning to overlook huddled street vendors, a Mercedes Benz billboard advertising the “best car in the world” stands spitting distance from the gross inadequacy of North Okkalapa hospital, its barely equipped wards overflowing with the sick and injured and without such luxuries as screens, mattresses or running water. There is one entirely free hospital in the country, the Muslim Free Hospital, where every religion and economic class is welcome. Elsewhere, bribes are commonplace, exacerbating the local mentality that healthcare exists only for those who can afford it.

Still, most of Yangon is several rungs up from Seikkyi’s grinding poverty, where U Aye Ko’s family of eight live in a hut the size of an average Australian bathroom sitting a foot above a sewerage-filled swamp that two two months to recede following August’s floods. His two-month old grand-daughter swings in a nest of blankets, tied to a rope hanging from the wooden beams. They live with their chicks and puppies and no utilities. All around, the waterlogged land is covered by a thick layer of plastic rubbish, a multicoloured crop that will never bear any fruit.

In the shadow of the NDP’s election win, his wife, Daw Leh Leh Win, says with a smile, “I believe we will have a very developed future.”

Tonight, like every night, she will eat steamed rice cooked on an open fire, before sleeping surrounded by her seven family members and their newest chicks nestled in a hole under the bedboards.

 

CHU CHU: Dala, Yangon

Scrunch a plastic bag and it might sound a little like “chu chu”. And so, partly inspired by the homophone, Wendy Kamhuailamhcing sits in her small family home in the Yangon suburb of Dala managing the cottage industry of ChuChu, which sells recycled plastic accessories and homewares.

The enterprising grandmother couldn’t be in a better spot for the business – around her home, across Dala and further, spreading through Yangon and beyond – is a goldmine of plastic rubbish, a free resource for the enterprise she manages for Italian humanitarian organisation, CESVI. Plastic pollution sits in layer upon layer along roads, in fields, floating on the muddy banks of the Ayarwaddy and mingled amongst the lily pads of the near-permanently flooded plains to the south of the capital city. A staggering, multicoloured sea of discarded wrappers, bottles, plastic bags, flip-flops, cans, lids and packaging seems to have collected in and around Myanmar’s largest city. It is no exaggeration, that, in shared areas of some of Yangon’s poorer communities, there is more rubbish than clear space. The rainwater they rely on for survival becomes a plastic soup as soon as it hits the land.

With 20 families helping to sort, clean, cut, sew and assemble ChuChu’s signature tough plastic bags, bowls, woven baskets, handbags made from car inner tyres and wallets, scores of the goods, ranging from about $5 to about $40, are made from homes in Dala each week. They are sold online and in a boutique in Yangon.

In her small yard, she and her family have been experimenting with making bricks for a new showroom she is planning. Solar-melted and moulded plastic blocks have been a failure – the system they fashioned did not build up enough heat to properly melt the rubbish – but a mixture of crushed polystyrene and concrete has been a success and the lumpy grey blocks are piled high. A volunteer tightly presses sand into old soft drink bottles, which, when lidded and stacked in lines, will join the bricks to make solid, relatively permanent walls for the new structure.

It pays to be ingenious in a city in which civic care appears low down the list of priorities. A Japanese company is planning to build an incinerator-power generator in the city, we are told by hopeful locals, but for Dala, which does not yet have a bridge connecting it to the city, such luxuries are a long way off. Plans to build a road to connect the commuter suburb to the city proper are both political and faultering. Passenger ferries ply the wide river, delivering Dala’s workers to the city’s lowest paid jobs throughout the day and into the night. They cannot afford rent in the city, we are told, and rents in Dala are on the rise, too, as developers watch movement around the mooted road build.

As the local priest tells us, people here need basics, they need water, they need sanitation – and they expect progress to be slow.

For now, the Kamhuailamhcing family purposefully, quietly, turns the rubbish amongst which they live into a stream of livelihood, educating the community and clearing the littered land, one homemade brick at a time.

NORTH OKKALAPA GENERAL: North Okkalapa, Yangon

Nowadays, it takes around an hour to drive from central Yangon to Okkalapa, a neighbourhood near the airport, punctuated, as all Myanmar communities are, with the gleaming gold cones of local temples. The main roads are clogged with new cars, but a block or two back, where the congestion gives way to meandering paths and thigh-powered rickshaws, a sprawling set of low buildings connected by deep grass and shaded pathways sees a steady stream of pedestrian visitors.

North Okkalapa General Hospital is a calm place despite its choked wards, limited electricity, rooms with no running water, bare wooden beds and the immense pressure of a population to doctor ratio that is hundreds, if not thousands, times that of Sydney.

Originally designed to hold 400 beds, the unaltered buildings now hold 800 beds. Dogs wander along ward corridors, fading scrubs hang on makeshift washing lines between the buildings and street vendors sell plastic bags of curries and rice to inpatients and their visitors.

“It’s the most progressive hospital I have worked in in Myanmar. It’s full of energy and good people who really want to help, but the government is really not making it easy for them,” says Dr Tim Peltz, a Sydney-based plastic surgeon with MACF who annually runs surgical courses at the hospital.

“There is no good equipment, no proper wards or beds. It’s very limited but the doctors are amazing, they are well trained and they try to do the best with the resources that they have.”

He and three other MACF medical staff teach local doctors approaches to major hand trauma, common in Myanmar because of outmoded heavy machinery and poor workplace safety standards.

Malaria and diabetes are common and, Dr Peltz says, remoteness means that some patients present very late, making treatment more complex. And then there is folklore.

“Patients are often treated before getting to the hospital by local healers,” he says. “They have old traditional healing methods that are massages and oil treatments but they also buy cheap medicine from countries such as China and distribute these medicines to their patients without having insights into what is in the medicine and without any real knowledge of the illnesses these people have.”

But perhaps the most dangerous aspect of North Okkalapa General’s day-to-day business is its historical and political setting.

“Everything depends on the goodwill of some superior who might not always have the benefit of the patient in mind. It is still a very obeying society, the doctors are afraid to do something they’re not supposed to do.

“The work of the medical person is limited through the political systems – even if there are good ideas, they are very hard to get through the machine.”

The hospital is in need of blankets, beds, pillows, sterile gloves and sutures – items that are readily available in Myanmar, he says.

“But this hospital is public, is does not get enough funding to buy these simple materials. It’s a mismanagement of the whole system.”

One suspects that a mistake so long in the making will take just as long to be fixed.

ONE MORE DOCTOR: Leik Tho, Taungoo

The road to the hill village of Leik Tho is slow going. It is not only the landslides and small, forboding military camps, their fences fortified with sharpened bamboo stakes, that add to the hold ups, but a new rag-tag kind of an army: half a dozen boys clatter and careen down the tightly twisting, steep road on home-made skateboards, wooden wheels coming off before rolling into thick jungle. Then another stop, this time to meet a man whose badly broken ankle was operated on in the nearby city of Taungoo after meeting MACF doctors a year ago. Holding his X-rays up to the light, Sydney-based trainee doctor Dr David Ma checks on his progress. A long way to go.

It is an apt prognosis in this valley, three hours east of Taungoo, where a lone doctor serves the population of 40,000 and villages still reel from being disbanded, their men imprisoned, or made refugees in their own environs, or worse, we are told.

MACF is in Leik Tho to hold one its annual health clinics, free and open to all, hosted by the local convent, whose white-washed, modern spire stands seems out of context near the pagoda, its gold leaf glinting in the sun. Sisters sit cross legged in an outdoor kitchen, steaming vast pans of rice over open fires and making sure none of the 200 visitors, some of whom have travelled for more than a day by foot to be here, leave without a hot meal.

Such is Leik Tho’s remoteness that Dr Joyce Conolly designed a bicycle ambulance to help ease long journeys – a protoype, built in Sydney, was delivered last year and it is hoped that a container of bike stretchers may eventually be sent to Myanmar. The aim is that locals will learn from the concept, building their own versions of the simple, potentially life-saving, contraption.

Most of those seeking medical attention today are farmers and their families. They are watched by three soldiers, a welcome change to a similar MACF clinic two years ago, where there were about 25 soldiers. The charity has been given special clearance to carry out the desperately-needed check ups – military grip on the area, prized for its betelnut forests, is softening, but for locals’ health care and living standards, improvements are yet to arrive.

“Although there’s been this election success after 25 years, you wouldn’t know it as far as I was concerned, except they’re less worried in their faces,” says Prof Conolly during the clinic, where it is quickly noted that most, if not all, of those waiting have never had their blood pressure taken in their lives. Patients with mouth cancers (caused by betelnut chewing), multiple sclerosis and suspected malaria are seen to alongside worryingly common appearances of diabetes, alcoholism and – as in the developed world – stress-related back problems. Arrangements are made for cancer sufferers to be taken to the nearest chemotherapy centre, seven hours away in the capital. Two teenage boys with MS are given wheelchairs, provided to MACF by the Rotary Club. They leave, for the first time in their lives, not on their fathers’ backs.

“There’s frustration in not being able to do more but then the recognition that unless this team of ours had not come to support Dr Wong, these people would not be able to afford to go for medical treatment in town. They would not be able to afford medicines,” the professor, who is in his 80s, says.

“They have a sense of being helped and a sense of being respected and they have a degree of confidence in the future.”

At the village hospital – a single ward caring for four inpatients on wooden beds, all of whom are young men with alcoholic neuropathy, and the other a small clinic – is the lone doctor, a 28-year-old from southern Myanmar, and two nurses.

He is nearing the end of an operation on a boy whose hand is severely infected. No local anaesthetic is used – the boys in this village are “strong and tough,” he says with a wide smile.

Yes, he needs help, he says, but only one doctor is allowed per village and so he focuses on realistic goals for now: he urgently needs a suction machine, some surgical instruments and a vehicle.

As we leave, the doctor cautiously shows some optimism for life after the long-awaited government transition: “I hope I may be joined by one more doctor next year.”

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Images, from top: Patients waiting to see visiting MACF doctors, Leik Tho (Daisy Dumas). Seikkyi waterfront (Daisy Dumas). Inside Yangon’s Muslim Free Hospital, a scene not unlike that in North Okkalapa General Hospital (Dr Tim Peltz). Nuns cooking for visitors to Leik Tho’s makeshift annual clinic (Daisy Dumas).

My visit was partly funded by MACF. This story was written shortly after my visit to Myanmar in November 2015.