Could proper medical care have saved Raysuana?
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
So Ma Li Khatu, Raysuana’s “second mother”, stands in front of her adopted daughter’s grave.
Raysuana poses for a photo sent to her brother in Malaysia.