The medical crisis in Manipur

By Anand Zachariah and Ramani Atkuri

We write this article to draw urgent attention of the general public and the medical community to the medical and humanitarian crisis in Manipur continuing now for more than 100 days. This article is written based on first-person accounts of health professionals and health volunteers working in Manipur and situation reports from non-governmental organisations. We aim to briefly highlight the present health situation, the health implications and what needs to be done to address this.

The situation

The violence, arson and killings in Manipur have resulted in a large number of internally displaced persons (IDPs) living in temporary shelters, both in the valley and in the hills. These shelters are in any vacant space where people can stay such as schools, hostels, godowns, places of worship, or community halls. Local people and civil society organisations are providing relief to the best of their ability, but it is insufficient to meet the needs of the affected. Many of the affected have left the State and moved to neighbouring states (Nagaland, Assam, Mizoram etc) or to far-off places like New Delhi and Bangalore if they happen to have family or relatives there.

Over 70,000 people are internally displaced, 142 casualties reported, and over 6,000 injuries reported

Due to the ongoing conflict, there is now an informal territorial division between the valley and the hills, with movement of people, goods and vehicles restricted between the two regions. All this is known but we fear the extent and scale of the crisis has not fully sunk in.

At present, in a volatile and dynamic situation, over 70,000 people are internally displaced, 142 casualties reported, and over 6,000 injuries reported. These displaced individuals are seeking shelter in 253 relief camps located across 10 districts of Manipur, according to data from Sphere India, a national coalition of humanitarian agencies in India. The reports have been made based on meetings of the Inter-Agency Coordination Committee (agencies involved in relief) and mapping of the response of more than 100 local organisations using the United Response Strategy (URS) matrix.

The health situation in Manipur

According to doctors who are working there or have visited, the health situation in the camps is grim, especially for the more vulnerable. There is overcrowding with inadequate arrangements for sanitation. Water is stored in large plastic tanks and is filled from a tap or borewell outside, but is not otherwise disinfected. Drainage of waste water is inadequate and with the onset of the monsoon, sanitation and drainage are set to become worse. There is a danger of disease outbreaks in such overcrowded conditions with inadequate facilities. Bed nets have been provided to some of the displaced persons. Diet is mainly two meals of dal and rice, with very few vegetables or meat occasionally. There is minimal provision for care of young children, pregnant and lactating women and the elderly.

There is a danger of disease outbreaks in such overcrowded conditions with inadequate facilities

Antenatal care, and routine immunization services have been disrupted. There is inadequate supply of drugs like anti-hypertensives or anti-diabetics. Deliveries are taking place in these ill-equipped camps, and it is difficult to take seriously ill patients to hospital. There are also several drug users in the relief camps who need care and rehabilitation services. There are no facilities for people with disabilities.  There is no work, and no way people can get money to purchase drugs from outside. Patients particularly from the camps and conflict zones find it difficult to reach the hospital.

Referral health facilities (as well as educational facilities) are located in the valley and hence are currently inaccessible to people living in camps in the hills. Other public health infrastructure, though also present in the hill areas, has more vacant staff positions than in the valley. There is acute shortage of specialists, medicines, and consumables in these health facilities. The recent conflict has just compounded the problem of an already weak health system.

Manipur’s health indicators of infant mortality rate, maternal mortality rate and under-5 malnutrition are better than the all-India average (SRS 2020). Some of these health indicators may worsen if the current situation of unrest continues in the state. 

There is acute shortage of specialists, medicines, and consumables in these health facilities

People are grieving the loss of their family members, as well as the loss of their property and livelihoods. Living in camps for three months has been stressful in the overcrowded conditions. There is also anger and resentment in both communities against the other. Children are traumatized by the displacement and sometimes by the loss of a parent or sibling. Uncertainty about the future and about being able to go back home has added to the stress and mental health problems. Agricultural activity has been affected by the conflict with people fleeing their lands for safety. School children, college students and those doing professional courses are unable to resume their studies. Kuki students cannot go back to their colleges in the valley for fear of being attacked and the future seems uncertain to them.

Call to action for health care professionals

The humanitarian and public health crisis in Manipur is exceptional. The violent conflict between two communities is leading to loss of life and large-scale displacement. These are paralysing the health system and will have adverse short-and long-term health outcomes.

The government is trying to provide services but in the face of the continuing violence and displacement of people, it is important for the wider medical and public health community to respond and supplement these services.

The immediate health needs are for medical supplies as well as for personnel. There is a need for:

1. Medical professionals to volunteer for providing primary care with priority given to pregnant mothers, young children, elderly, and those with chronic disease.
2. Volunteers who can provide grief and trauma counselling and /or train local people to provide this.
3. Basic health training for lay volunteers with provision of health kits to treat minor ailments, provide first aid and conduct disease surveillance.
4. Drugs and supplies

Call to action for the Government

It cannot be emphasised enough that the return to peace as soon as possible is of the highest priority through initiating confidence building measures with both communities. The government must ensure relief and rehabilitation in a non-discriminatory manner. 

We identify the following priorities:

1. Government to take full responsibility for running all camps including provision of proper nutrition, safe drinking water and sanitation.
2. Ensure availability of health care services in the camps.
3. Strengthening public health institutions in rural areas.
4. Need to restore identity documents of people who have lost them.
5. Safety of women, prevention of sexual harassment and quick response in case of sexual violence.
6. Safe passage for health personnel and medical supplies should be allowed to reach both patients and facilities.
7. Enable medical, nursing and allied health science students to resume their studies within or outside the state.
8. Rehabilitation of affected persons as soon as possible.

While resolution of the conflict can only occur through sustained political effort and inter-community reconciliation, it is imperative that we, as members of the medical fraternity, and as Indian citizens, work to alleviate what suffering we can until lasting peace can be achieved.

(Dr. Anand Zachariah is Professor of Medicine, Christian Medical College, Vellore. Dr. Ramani Atkuri works with tribal and rural communities in Central India, with special interests in communicable diseases, women’s health, hunger and malnutrition. Views are personal)