When I was selected in 1989 to learn Burmese before going to serve as second secretary at the British Embassy in Rangoon, the then ambassador, on discovering that my degree was in pathology, commented that it was a better training for understanding the state of Burma than any political science PhD. As I leave Burma after three and a half years as ambassador, I can see what he meant. And sadly in 2006 the Burmese patient appears to ail as much as ever, after showing brief signs of recovery between 1989 and 1997. That followed some changes to the country's lifestyle, such as a brief flirtation with a market economy, before reverting to old central planning habits.
The job of a pathologist is to look at etiology (what causes a disease); pathogenesis (how it does it); morphologic changes to the structure of the cells, tissues and organs; and clinical significance: what the effect is of those changes, or the symptoms of the disease.
The symptoms of the Burmese patient have been well documented over the years. They include stunted development and a dysfunctional economy, in which cronyism means that a mobile phone costs 50 times as much as in neighboring countries, and a 25 year-old 'end-of-life' vehicle you'd have to pay to have taken away in Britain is worth US $20,000. Artificially inflated transport costs have a knock-on effect all the way down to the poorest citizens. Even better documented symptoms are the lack of freedom and widespread human rights abuses, particularly in conflict zones, and ethnic discrimination.
On the other hand, there have been some improvements. Parts of the country that I could not visit during my first posting in 1990-1993, such as Hpa-an, Pangsang and Kachin State, are now easily accessible because of ceasefires and investment in transport infrastructure. The bridges and roads of which the government is so proud have had a genuinely significant and overall positive impact on former war zones and subsistence agricultural economies, stimulating new markets, and permitting development projects.
Yet despite this, Burma is still ailing. While the top leadership may publicly dispute this, and statistics are either lacking, contested or unreliable, the clearest symptom of the country's poor economic and political health that I have encountered in my travels is that almost everyone I have met either wants to leave the country themselves, or send their children abroad, to work or to study, where they can live in a climate of less insecurity and greater freedom. Even the minister responsible for announcing growth figures of 10-12 percent tells me proudly of his children working and studying in Singapore and Australia. Denied the opportunity to vote through a ballot box since 1990, people are voting with their feet. Although remittances from overseas workers to their families are a positive form of targeted aid, the social fabric and culture of the country is suffering from this emigration.
Yet the Burmese patient has not lacked advice from a concerned international community on how to get fit and healthy. Treatments have been endlessly prescribed, including by qualified "doctors" such as the IMF, Japanese economists, and Amnesty International, whose detailed and objective 2003 report Access to Justice was left unopened by the patient in the bathroom cupboard. Other advice has come from friends and family concerned by the worsening health of their loved ones. Some has been sensible; but some suggestions have arisen out of desperation when no treatment appeared to be working, or have been based on incorrect information or diagnoses, or out-of-date medicines.
The patient has been exposed to quacks too, just like the omnipresent Burmese village "injector" who flogs a handful of multi-colored pills or herbs claiming they will cure HIV. Quacks have no interest in preventative care, and questionable interest in long-term recovery, since it could damage future business prospects. Some are prescribing Burma the equivalent of a blow to the head, or a starvation diet.
Regardless of the motivation or qualifications of those prescribing the medicine, the main thing to remember is that our goal should be the Burmese patient's sustainable recovery. This was brought home to me by a presentation at a recent Burma Day conference in Brussels, where one activist produced graphs to show that the campaign objectives of his organization had been increasingly achieved year-on-year. Yet the rest of us at the conference, Burmese and non-Burmese alike, had been standing around the patient's bed all day unanimously agreeing that he had never looked in a worse state of health.
It would be a mistake to believe that there can be a miracle or rapid cure. Many other less developed and even better developed countries suffer from the same symptoms as Burma, such as poverty, corruption, inequality, unsustainable natural resource exploitation, lack of freedom, and a growing burden of HIV. Many countries are sicker than Burma on some or all of these counts. Treatment for systemic problems is never straightforward.
But we-government, activists and international community alike-would be helped by applying the principles of evidence-based medicine and clinical audit to policy and activities. Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Audit is the systematic and critical analysis of the quality of care, including the procedures used for diagnosis and treatment, the associated use of resources and the effect of care on the outcome and quality of life for the patient.
So we need more research, and more evaluation. In particular, we should review how countries such as Chile, Vietnam, China, Thailand and Korea recovered (or are recovering) from military and one-party dictatorship, and consider the relevance of that experience to Burma. And policies, whether they are implemented by the Burmese government, the international community, opposition or exiles; whether mass planting of physic nut bodies, banking sanctions, or banning ethnic languages from the primary school curriculum, should be openly and honestly evaluated for their short and long-term impacts and effectiveness. Lack of accountability is a big problem inside the country, but it is also a problem with the opposition and exiles. Audit should also include lessons to be learned from success stories, such as the shift in government attitudes to HIV/AIDS, and the boom in beans and pulse exports which has benefited dry zone farmers. In the latter case, an unusually laissez faire approach by the government, which allowed farmers to grow crops freely and respond to market mechanisms and incentives, supported by a domestic banking infrastructure which facilitates the work of brokers across the country, were key factors promoting economic growth.
The political equivalent of physiotherapy and rehabilitation is also necessary. The different parts of the body politic need to be exercised and slowly learn to cooperate with one another, across political, ethnic and social divides. Healthy muscles are antagonistic; they pull against one another, in conflict. Yet together they result in movement.
Full organ transplantation is a risky last resort. So more needs to be done to heal and strengthen Burma's existing internal organs such as the education system, the judiciary and the police, through a diet of capacity-building. Unhealthily enlarged organs, such as the military, need to be reduced to the correct size so that they function more efficiently. And the backbone of civil society needs to be strengthened.
Pathology derives from the Greek word pathos, which means "suffering, feeling, emotion." These are common feelings for all who work to try and bring about change in Burma. But I believe we need to put emotions aside, and take a dispassionate look at the evidence, and draw appropriate conclusions.