Could proper med­i­cal care have saved Ray­suana?

The Myanmar Times - - Front Page - FIONA MACGRE­GOR f.macgre­gor@mm­times.com

The sec­ond in­stall­ment of an in­ves­ti­ga­tion into the death of a Mus­lim woman in Rakhine State looks at the in­sti­tu­tional fail­ures that pre­vented her from re­ceiv­ing po­ten­tially life-sav­ing hos­pi­tal treat­ment.

On Septem­ber 23, The Myan­mar Times pub­lished the first of a twopart se­ries about Ray­suana, a young Rohingya woman who was dis­cov­ered semi-con­scious at a mil­i­tary com­pound in Sit­twe town­ship on Au­gust 18 and who died 12 hours later with­out be­ing taken to hos­pi­tal or any kind of crim­i­nal in­quiry hav­ing been launched. To­day we look at what hap­pened to her af­ter she was found, and reveal why she did not re­ceive the med­i­cal at­ten­tion she so des­per­ately needed.

WHEN Ray­suana ar­rived at Thet Kya Pin Clinic at around 8am on Au­gust 18, the odds were al­ready stacked against the young woman who had been found naked and in­jured in the bushes at a mil­i­tary com­pound ear­lier that morn­ing.

The fa­cil­ity is a ba­sic health cen­tre for mem­bers of the Mus­lim Rohingya mi­nor­ity who are de­nied free­dom of move­ment by state au­thor­i­ties and are usu­ally re­quired to go through a com­pli­cated re­fer­ral process be­fore they are al­lowed to go to the nearby state hos­pi­tal.

It would be an­other hour un­til the state doc­tor would turn up for duty, and so the Thet Kya Pin vil­lage ad­min­is­tra­tor U Hla Myint handed Ray­suana over to the clinic’s med­i­cal as­sis­tants for care. She was placed on the bare metal slats of one of the clinic’s mat­tress­less beds to await the doc­tor’s ar­rival.

Some clothes were hur­riedly found and a woman at the clinic dressed Ray­suana, not­ing as she did that there was blood around the young woman’s vagina.

“On the way to the clinic, I called to po­lice and re­ported it and then I re­ported it to [a sec­ond] po­lice sta­tion,” said U Hla Myint, who had been con­tacted ear­lier that morn­ing by of­fi­cers at the nearby mil­i­tary com­pound where Ray­suana had been found and told to take her to the clinic.

“I ar­rived with her at the same time as the po­lice got there,” said U Hla Myint.

But the po­lice, who are un­der the au­thor­ity of the mil­i­tary, did not open a crim­i­nal case.

U Hla Myint set off to the neigh­bour­ing camps and vil­lages to find out if any­one knew of a miss­ing woman. Ray­suana’s mother had fled to Malaysia af­ter ri­ots broke out between eth­nic Rakhine and Rohingya Mus­lims in 2012, leav­ing 140,000 dis­placed. Ray­suana had been taken in by an­other fam­ily.

A vic­tim of sex­ual as­sault, or psy­chi­atric episode?

The “in-pa­tients” sec­tion of Thet Kya Pin Clinic is, in re­al­ity, more out­side than “in”. No wall sep­a­rates the open-sided “ward” from the rest of the sparse health fa­cil­ity, and the male and fe­male pa­tients who lie on the few beds are en­tirely ex­posed to pub­lic view.

Such cir­cum­stances are far from ideal for any vic­tim of gen­der-based vi­o­lence.

But de­spite Ray­suana hav­ing been found naked, other than a bra, and de­spite the fact that the woman who helped care for her when she ar­rived at the clinic re­ported pos­si­ble in­juries to her vagina, Ray­suana was not treated as a po­ten­tial vic­tim of GBV.

In­stead, sources have told The Myan­mar Times that af­ter the state doc­tor ar­rived she was clas­si­fied as a psy­chi­atric case.

This is un­der­stood to have played a sig­nif­i­cant role in why more ef­fort was not made to en­sure she re­ceived the nec­es­sary per­mis­sion to be taken to the nearby state hos­pi­tal for proper ex­am­i­na­tion and treat­ment.

The al­le­ga­tion has been de­nied by the state health de­part­ment, which told The Myan­mar Times that be­cause Ray­suana was un­able to speak, the doc­tor could not as­cer­tain whether her con­di­tion was psy­chi­atric in na­ture or not.

How­ever, med­i­cal staff who at­tended the clinic later in the day are un­der­stood to have been told Ray­suana’s was a psy­chi­atric case and ex­plained to their se­niors later that they were not in­formed of the cir­cum­stances in which she was found.

The rea­son for the dis­crep­ancy in ac­counts is un­known. What is clear, how­ever, is that due to in­ad­e­quate med­i­cal as­sess­ments, a flawed and un­clear set of re­fer­ral pro­to­cols, and fear of reprisals, Ray­suana was not treated as an emer­gency case nor as a pos­si­ble vic­tim of sex­ual vi­o­lence.

The pos­si­bil­ity that a con­fused, naked and in­jured young woman may have suf­fered a sex­ual as­sault and/or trau­matic head in­juries – with po­ten­tially life-threat­en­ing in­ter­nal in­juries – did not ap­pear to be con­sid­ered sig­nif­i­cant enough to ei­ther of the male doc­tors who treated Ray­suana that day, nor to hos­pi­tal au­thor­i­ties, to en­sure she re­ceived an emer­gency re­fer­ral.

“I be­lieve if she’d been taken to hos­pi­tal, she would have lived,” said one wit­ness with a med­i­cal back­ground who saw Ray­suana at dif­fer­ent mo­ments from her ar­rival at the clinic un­til her death.

An act of kind­ness hides the truth

Dress­ing Ray­suana was an act un­der­taken to re­store her mod­esty. How­ever, once she was clothed in a high-necked blouse and longyi, no fur­ther ex­am­i­na­tion was un­der­taken to de­ter­mine whether she was a vic­tim of gen­der-based vi­o­lence, or had in­ter­nal in­juries.

In­deed, such was the re­luc­tance of the state doc­tor to ex­am­ine her at all that he ap­pears to have missed in­juries even to less in­ti­mate parts of her anatomy.

The Myan­mar Times spoke to three dif­fer­ent med­i­cal work­ers in­volved in Ray­suana’s treat­ment and each, sep­a­rately, men­tioned her most ob­vi­ous in­jury was one to the back of her shoul­der.

Yet ac­cord­ing to the state med­i­cal de­part­ment, no such in­jury was recorded in Ray­suana’s med­i­cal notes. When The Myan­mar Times asked Dr Thaung Hlaing, the state pub­lic health di­rec­tor, about this, he sug­gested the fact that she was clothed by the time the doc­tor saw her meant the wound was likely missed.

As for the pos­si­bil­ity that Ray­suana had been sex­u­ally as­saulted, he ap­peared scep­ti­cal.

“For rape – I don’t agree,” said Dr Thaung Hlaing. “We can’t even see … could not see for med­i­cal rea­sons. Our doc­tor was also re­luc­tant to han­dle her,” he said, re­fer­ring to the fact that there was not a qual­i­fied fe­male nurse or doc­tor present.

The state doc­tor did do a ba­sic ex­am­i­na­tion of Ray­suana, check­ing her “ex­trem­i­ties” and analysing her state of con­scious­ness.

“Our doc­tor ex­am­ined her [us­ing] the Glas­gow Coma State [assess­ment] and she was in the mid­dle, bor­der­line. He in­formed us and started the trans­fer [process to send her] to the city gen­eral hos­pi­tal,” Dr Thaung Hlaing.

Pro­tect­ing rep­u­ta­tions, risk­ing lives

But a sec­ond prob­lem was com­ing to the fore. No one in the com­mu­nity had been found to iden­tify Ray­suana and there were no rel­a­tives to give any form of med­i­cal con­sent, so there was no one to travel with her to the hos­pi­tal as an at­ten­dant.

Ac­cord­ing to in­ter­na­tional agen­cies based in Sit­twe, in an emer­gency sit­u­a­tion a pa­tient can be trans­ferred to the hos­pi­tal from Rohingya camps or vil­lages with­out an at­ten­dant.

Un­der “right to life” pro­to­cols and given the high pos­si­bil­ity that Ray­suana’s un­con­scious or semi-con­scious state at the time she was found in­di­cated the pos­si­bil­ity of se­ri­ous head trauma, she should have been sent straight to the hos­pi­tal from the mil­i­tary com­pound rather than the clinic, an in­ter­na­tional ex­pert in the state cap­i­tal said.

But even fol­low­ing the doc­tor’s rec­om­men­da­tion at the clinic, the lo­cal com­mu­nity and the med­i­cal au­thor­i­ties were re­luc­tant to send Ray­suana to hos­pi­tal alone, and med­i­cal au­thor­i­ties de­nied her a trans­fer­ral un­less she had an at­ten­dant.

“Our de­part­ment was ready to as­sist her to come, but un­for­tu­nately there was no one to come with her,” said Dr Thaung Hlaing. “I’m not mak­ing ex­cuses; that’s just what hap­pened.”

Among the many ru­mours that abound in eth­ni­cally and re­li­giously di­vided Sit­twe, one in par­tic­u­lar strikes fear into the heart of the Rohingya com­mu­nity: There is a com­monly held be­lief that Mus­lim pa­tients who go to Sit­twe Hos­pi­tal are de­lib­er­ately hurt or even mur­dered by the eth­nic Rakhine staff who work there.

While re­ports of care­less or in­sen­si­tive treat­ment of Rohingya pa­tients have on oc­ca­sion been ver­i­fied by wit­nesses, no ev­i­dence has emerged of de­lib­er­ate harm, let alone mur­der.

Re­gard­less of their ve­rac­ity, the im­pact of these ru­mours has been sig­nif­i­cant. Not only were mem­bers of the Ro­hyinga com­mu­nity re­luc­tant to send Ray­suana to hos­pi­tal un­ac­com­pa­nied, but also hos­pi­tal au­thor­i­ties re­fused to take her amid fears they could be held re­spon­si­ble were she to die with­out a wit­ness from her own eth­nic back­ground.

“The other [Rohingya] com­mu­nity still doesn’t have trust in our hos­pi­tal. If we ad­mit­ted her with­out an at­ten­dant and she died, we can’t ex­plain why or what we did,” said Dr Thaung Hlaing.

He added, “They don’t dare ac­cept her in case the me­dia or the in­ter­na­tional com­mu­nity say some­thing.”

Too fright­ened to get in­volved

As the vil­lage head U Hla Myint’s ef­forts to find any­one who knew the in­jured young woman con­tin­ued to prove fruit­less, he asked if any­one else from the com­mu­nity would be will­ing to ac­com­pany her to hos­pi­tal, but no vol­un­teer came for­ward.

“They were not her rel­a­tives and they were afraid the girl would die in hos­pi­tal. They didn’t want to be in­volved,” he said.

With no one to ac­com­pany Ray­suana, and the hos­pi­tal re­fus­ing to take her alone, the doc­tor put her on a drip and ad­mit­ted her to the clinic while the search for her fam­ily con­tin­ued.

“We have the drip-line there and put these mea­sures in front of peo­ple,” said Dr Thaung Hlaing.

He added that if Ray­suana died at the clinic with wit­nesses there, it would cause fewer prob­lems than were she to die alone in hos­pi­tal with no one from her com­mu­nity to wit­ness what had hap­pened.

“My doc­tor was very re­luc­tant even to touch her, [other than] for life-sav­ing mea­sures.”

As for en­sur­ing she was treated for a pos­si­ble sex­ual as­sault, “If we’re in­formed there’s been an as­sault we’ll check but other­wise we can’t. If it’s not a po­lice case, we can’t and the po­lice did not in­form us,” he ex­plained.

Ac­cord­ing to those work­ing on gen­der-based vi­o­lence is­sues, it does not legally re­quire that a for­mal po­lice case be opened for an in­ci­dent to be treated as pos­si­ble GBV. This is not some­thing those in­volved in Ray­suana’s case ap­peared to be aware of, or will­ing to put into prac­tice.

“She was very un­lucky. My doc­tor didn’t see any red [blood stain] on her longyi,” Dr Thaung Hlaing added, say­ing that with­out such clearly vis­i­ble ev­i­dence, the doc­tor was un­able to act.

A sec­ond chance for help missed

At around 2:30 that af­ter­noon – by which time Ray­suana had been ly­ing in the open fa­cil­ity for around six-anda-half hours hav­ing had only the most cur­sory of ex­am­i­na­tions – a doc­tor from the INGO Mercy Malaysia ar­rived to take over med­i­cal care at the clinic.

Ac­cord­ing to sources, Ray­suana, hav­ing been ad­mit­ted to the clinic as an in-pa­tient, was not con­sid­ered to be un­der his charge as the or­gan­i­sa­tion was tasked solely with out-pa­tient treat­ments and hos­pi­tal re­fer­rals that af­ter­noon.

The Mercy Malaysia doc­tor did, how­ever, ex­am­ine her “in­for­mally”.

“As soon as [the doc­tor] re­alised she was semi-con­scious, he said she should be re­ferred to hos­pi­tal and called for an am­bu­lance,” said one source present at the time.

The source said the doc­tor did not be­lieve Ray­suana was at im­mi­nent risk of death, but con­sid­ered it im­por­tant that she re­ceive X-rays and other med­i­cal checks that could not be car­ried out at the clinic due to its lack of fa­cil­i­ties.

“But the prob­lem was [she] needed a se­cu­rity guard and a pa­tient at­ten­dant, but they said she’s’ ‘un­known’ and there was no at­ten­dant so [the doc­tor] can­not re­fer her,” said the source.

Ac­cord­ing to the source, “[The doc­tor said he] didn’t know how se­ri­ous Ray­suana’s con­di­tion was, but be­cause of the sit­u­a­tion it did not look like an emer­gency. Her con­di­tion was sta­ble.”

Asked why this sec­ond doc­tor had not fol­lowed up on the pos­si­bil­ity that Ray­suana had been a vic­tim of gen­der­based vi­o­lence, an­other source close to the case said the doc­tor had not been made fully aware of the cir­cum­stances in which the young woman had been found.

The source said that ac­cord­ing to his un­der­stand­ing of events, Ray­suana had gained some con­scious­ness and at times had been able to get up and was act­ing er­rat­i­cally.

“[The Mercy Malaysia doc­tor] saw this woman pulling out her drip and wan­der­ing around in­co­her­ent and ac­cepted the assess­ment of the state doc­tor who had ad­mit­ted her – that she was a psy­chi­atric case,” the source said.

It should be noted that no di­rect wit­nesses, in­clud­ing med­i­cal staff, spo­ken to dur­ing in­ter­views in Rakhine State de­scribed such be­hav­iour by Ray­suana.

U Hla Myint, the vil­lage ad­min­is­tra­tor, re­turned to the clinic at around 5pm.

“I said to the doc­tor, ‘No one wants to take care of her in hos­pi­tal so what should we do?’ The doc­tor said, ‘Let her stay one night [at the clinic] and check on her con­di­tion.’”

By 6pm, the Mercy Malya­sia doc­tor left the clinic for the night, leav­ing Ray­suana in the care of Yas­min (not her real name), a Rohingya woman who had worked at Sit­twe Gen­eral Hos­pi­tal be­fore the in­ter-com­mu­nal con­flicts of 2012 and acted as a nurse at the clinic.

Around an hour later Ray­suana died, hav­ing re­gained the abil­ity to speak in the last min­utes of her life when she called out for her mother.

“She was very un­lucky,” said Dr Thaung Hlaing. “If she could have over­come the night, she could have come to the hos­pi­tal.”

A fi­nal in­dig­nity

Early the fol­low­ing morn­ing, U Hla Myint’s at­tempts to dis­cover Ray­suana’s iden­tity fi­nally had some suc­cess – although it was too late for the young woman.

He re­ceived a mes­sage that some­one knew of a girl match­ing Ray­suana’s de­scrip­tion who had been liv­ing in Ohn Taw Shay and then later Let That Mar vil­lages.

It emerged that as well as her “sec­ond mother” at Ohn Taw Shay, where Ray­suana had stayed for three years af­ter be­ing dis­placed in the 2012 ri­ots, as well as Su Ra Ka Tu, the mother of her friend in Let That Mar, with whom she had been liv­ing be­fore her dis­ap­pear­ance, she also had a cousin by mar­riage liv­ing on the out­skirts of Thet Kya Pin.

But like oth­ers in the com­mu­nity, Ray­suana’s rel­a­tives did not want to get in­volved ei­ther.

Idris, an el­der from Let That Mar, takes up the story.

“We found out what had hap­pened when the head of the vil­lage [U Hla Myint] came to us,” he said.

Her Let That Mar friends col­lected Ray­suana’s body from the clinic and car­ried her to her rel­a­tives’ home.

“But they were not close rel­a­tives and they didn’t want to bury her. That’s why we had to take her back here,” Idris ex­plained.

“There was no in­ves­ti­ga­tion, but we re­ported it to the po­lice at the gate [the check­point for peo­ple en­ter­ing the Rohingya vil­lages].

“At first we waited for some in­ves­ti­ga­tion and then we asked the po­lice and the head of the vil­lage how we should pro­ceed. We were told it’s a nor­mal in­quiry for this case so we can bury her now.”

Stand­ing by the patch of earth where she laid Ray­suana’s body to rest last month, Su Ra Ka Tu re­calls the day she buried the young woman she had hoped would be­come a sis­ter-in-law to her daugh­ter.

“I first saw her body in the morn­ing af­ter she died and by the time we got her here to the vil­lage it was about 11am. I buried her at 4pm.

“We couldn’t call her fam­ily be­fore I buried her. At the time there was no phone con­nec­tion to Malaysia.”

Ray­suana was buried with­out an au­topsy or even a doc­tor’s dec­la­ra­tion as to cause of death. De­mands by Amnesty In­ter­na­tional for an in­de­pen­dent in­quiry have so far gone un­met.

As for the state health au­thor­i­ties and in­ter­na­tional agen­cies in­volved in this case, so far no pub­lic an­nounce­ment has been made as to what ac­tion will be taken to pre­vent such an in­ci­dent from hap­pen­ing again.

‘[The Mercy Malaysia doc­tor] saw this woman pulling out her drip and wan­der­ing around in­co­her­ent and ac­cepted the assess­ment of the state doc­tor .... that she was a psy­chi­atric case.’

Source present at the time

Photo: Fiona MacGre­gor

So Ma Li Khatu, Ray­suana’s “sec­ond mother”, stands in front of her adopted daugh­ter’s grave.

Photo: Sup­plied

Ray­suana poses for a photo sent to her brother in Malaysia.

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