Charlie Artingstoll examines the multifaceted challenges to mental health services in Myanmar.
With additional research by Hsu Myat Yadanar Kyaw Soe.
Read the Burmese version of this post, available here.
Before the coup, mental health was a neglected issue in Myanmar. Now, the situation is even worse. In this article, I look at the financial, legislative, structural and cultural challenges that have limited the provision of mental health services in Myanmar in the past – and how the coup continues to create shocks within this landscape.
Mental health in Myanmar is a critical issue. It is an unstable country, both in terms of political and economic factors. Decades of protracted conflict – the longest-running civil war in the world – combined, more recently with the economic impact of COVID-19, which according to a study in October 2020, saw the proportion of the population living in poverty rising from 16% to 63% over the past 8 months.
Moreover, since the February 2021 coup, violent crackdowns have already had, and will continue to have, a significant impact on citizens’ mental wellbeing. Senior UN officials warn of an ‘impending humanitarian crisis’ and have also argued that ‘Myanmar is spiralling into becoming something like a failed state’ with ‘potentially massive humanitarian ramifications’.
As Myanmar continues to exhibit more characteristics of a failed state, there will be serious ramifications for its population’s mental wellbeing. These ramifications can be seen in other conflict afflicted countries. According to a global WHO synthesis of 129 studies done in numerous conflict-affected contexts, ‘one in five people in conflict-affected populations have mental health conditions’. Conditions identified among these populations include depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia. The report concludes that, ‘given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden.’
In Myanmar, the mental health burden is being placed on an extremely strained system. A 2019 HelpAge International study further demonstrated the seriousness of mental health issues in Myanmar with the following findings: legally, ‘There is, [effectively], no mental health policy in Myanmar; preventing access to professional support through the primary healthcare system.’ While, as we shall see, some care is given through the private sector, this is limited in scope. Regarding state mental health provision, including funding, staff and infrastructure, the HelpAge study found that ‘staff are not adequately trained and there is little infrastructure to facilitate these services, particularly in rural areas’. As we shall see, much of this stems from a chronic lack of sufficient funding. Finally, the study pointed out that stigma and cultural understanding are also key issues: ‘while there is no data in Myanmar on how stigma impacts mental health, studies from other, similar countries suggest it has serious consequences.’
Going forward, the key challenges facing Myanmar’s mental health landscape are a lack of legislative support, a lack of funding, and misunderstandings about the nature of mental health. I shall explore these issues below.
Legislation and funding
Myanmar’s mental health legislation is outdated, to say the least. The nation’s mental health policy — I’m not making this up — is legislated by The Lunacy Act, dating from 1912. Violate this law at your peril – you’ll face a fine of 50 Indian rupees – a currency that has been obsolete since 1952. That Myanmar’s current mental health law focuses on criminalising ‘lunatics’ who pose a danger to society through incarceration at asylums goes a long way to explain the stigma that mental health currently has in the country, as we shall see later. To give an interesting parallel example, The Lunacy Act was also used in India, yet was replaced in 1987 by the Mental Health Act (where, among other changes, lunatics were referred to as mentally ill persons, and asylums as psychiatric hospitals), and then again in 2017 by the Mental Healthcare Act, which explicitly stated the need to implement ‘programmes to reduce stigma associated with mental illness’, along with more generally empowering those affected by mental health issues – which it was felt that the 1987 act failed to do. In Myanmar, a new bill has ‘been discussed by relevant ministries and agencies [The Ministry of Health and the WHO] since 2013 but has not reached parliament,’ according to the Myanmar Times.
Myanmar’s mental health landscape is also shaped by its Mental Health Policy, which is part of its National Health Policy. Last revised in 2006, the National Health Policy sees 0.3%of total health care expenditures spent on mental health, versus a global median of 2% – in other words, mental health in Myanmar is woefully underfunded. Especially once you consider that up until 2012, Myanmar had one of the lowest rates of healthcare spending in the world. While spending since then has risen significantly, Myanmar’s national healthcare expenditure as a percentage of GDP is the lowest in the ASEAN region, and outside of Africa, remains one of the lowest in the world. Furthermore, one has to keep in mind how badly funded and managed healthcare was in Myanmar for so many years. According to DFID: ‘even with the increase, a much larger injection of funds is necessary to reverse decades of neglect and mismanagement.’
How the ongoing Civil Disobedience Movement (CDM) and the junta’s approach to healthcare governance will affect the healthcare system is yet to be seen, though it the impact of these shocks is unlikely to be positive. As we have seen, military rule in the past has coincided with chronic government underspending on healthcare, and their recent behaviour against any health workers who are deemed to be threatening the stability of the government does not bode well. As of early May, at least 97 healthcare workers have been arrested and 10 killed since the coup, while arrest warrants have been issued for 400 health workers participating in CDM. Thousands continue to strike, bringing the country’s public health system – which accounts for 80% of the hospitals and clinics in the country – to its knees. Striking doctors have set up their own clandestine clinics, yet these are overloaded and face the risk of arrest if discovered.
‘The public health system is near collapse,’ Dr Mitchell Sangma, who is on the ground for humanitarian organisation Medicins San Frontiers told the BBC. “It’s a grim situation”. Those who cannot afford private care, simply are going without any healthcare. Though no research is currently available, given how limited the public provision of mental health support is at the best of times, now, when even life-saving care is unavailable, it must be close to non-existent.
(Mis)understandings of mental health
Public understandings of mental health are also an issue of concern. I recently spoke to Nay Chi Soe (pseudonym), a student who graduated with a BA in Psychology from East Yangon University a few years ago, about mental health. Two things stood out. Firstly, how unpopular the course was: of approximately 4,000 students who graduated from the university in her year, she had three other course mates. It was the least popular course in her year. Even Library and Information Studies had around 10 students, while more popular courses such as Engineering and Law had hundreds of graduates.
The second thing that stood out from our conversation was the reaction from friends, extended family members and even fellow students when she told them what she studied; ‘Oh do you want to go to a Ywa Thar Gyii?’ (Yangon mental hospital).’ ‘So can you tell me, were the crows black or white originally?’ (a Burmese equivalent of whether the chicken or the egg came first). These comments go some way to show how misunderstood the subject is. Indeed the crow comment is a philosophical question: the chicken/egg or white crow/black crow is a philosophical paradox about the nature of causality that has nothing to do with psychology at all. And even when people don’t confuse psychology with another subject, they tend to associate psychology with extreme mental illness. The subject is deeply misunderstood.
There are, however, more promising signs, most notably in the private sector provision of mental health. One of the most active groups in the mental health field in Myanmar is the Yangon-based, UNFPA-funded Mental Health Psychosocial Support (MHPSS) Working Group, which has half a dozen suppliers in its list of available services.
Aung Min Thein, the founder of Counselling Corner, a private mental health CSO based in Yangon, explained how they address the problems facing the provision of mental health services in Myanmar.
According to him, ‘we have found that Myanmar people are not very familiar with counselling and generally don’t want to burden the system. This is the result of two main factors, the lack of information and stigma that mental health currently has in the country, and arr nar dal – the feeling of not wanting to impose oneself. It is therefore vital that we take a pro-active approach to mental health provision – while passive techniques have an important role to play, real results require real and meaningful interaction between the target groups and mental healthcare professionals. We have found that interactive workshops offer the best environment for therapy as they encourage people to talk freely in small groups about themselves – often realising that they share the same emotions, feelings and experiences.’
Mental health in the wake of the coup
Looking forward, addressing these financial, legislative, structural, and cultural changes will take time, particularly given the current political situation. The junta government has made it clear that it will not accept any criticism of its rule, which causes a problem for any mental health campaign. While mental health was certainly an issue in Myanmar before, it is an issue that has wholly been exacerbated by the military coup and the subsequent, and ongoing, destruction that has followed. Even for those who have not directly experienced extreme traumatic experiences (like being imprisoned, physically attacked etc.), anyone with a Facebook account will have been exposed to content that poses severe mental health risks. Factor in stresses related to the severe economic implications of the coup, such as mass unemployment and financial insecurity, may also act as triggers on top of the previous existing challenges caused by Covid-19, past traumas, or even the normal difficulties in a person’s life.
The coup puts mental health at an impasse: many of the mental health issues people will be experiencing will be caused directly by the coup, yet any treatment likely cannot explore these issues or place any blame, lest they run the risk of censorship – or worse. However, as Aung Min Thein tells me, the importance of therapy is not about placing the blame on somebody or something, rather about working on one’s own issues. His approach is to focus on the feelings of the individuals rather than the stimuli that caused them. This strategy does not legitimise the coup, but rather a recognition that the resilience people require to resist the regime depends on their mental wellbeing.
While the situation seems bleak, the first step at least is clear: we need to deal with the stigma associated with mental health in Myanmar, and to help people realise that asking for mental health support is both completely normal and healthy. Only then can mental health issues in Myanmar be truly addressed.
A number of both national and international volunteer-based counselling groups have sprung up since the coup. Readers may also refer to MHPSS’s list of available services.
Charlie moved to Yangon in 2014 to work at UNODC. After winning the war on drugs, he worked at BRAC. Then he realised he didn’t like working for INGOs and started running music events. Fast-forward 2 years, he started a record label with local artists. Now, he works with celebrities and influencers in social media campaigns that communicate socially beneficial messages. He speaks pretty good Burmese. He also runs a watch company. Charlie has written on Microfinance and the Ultra-poor, the War on Drugs , Suu Kyi and Islamophobia, and the hip hop scene in Myanmar