The Burden of Conflict on Manipur's Healthcare: An Evolving Humanitarian Crisis

Thousands of those affected in the state have been virtually cut off from routine medical services amid insecurity.

(This is part of a series of field based reports spotlighting lesser known cross-cutting humanitarian issues that are emanating from the ongoing conflict in Manipur. In addition to understanding the socio-economic impact of the conflict, the series also seeks to map out instances of resillence, local innovations in humanitarian action and examples of community peacebuilding in the context. The Mapping Humanitarianism Initiative is being undertaken by the Centre for New Economics Studies (CNES) in close collaboration with Peace Centre Nagaland located in Chümoukedima.)

There is a growing tendency to quantify the impact of violence, human loss, and, brutality in numbers that stems from the normalisation of violence permeating the media landscape covering conflict. The greater the intensity, the numbers keep elevating which does not always reveal the real picture. A similar situation is unfolding in the state of Manipur – the site for India's biggest humanitarian crisis which the mainstream coverage seems to be taking a distant approach towards.

The underlying story being – since the outbreak of ethnic conflict in Manipur in early May, there has been a resurgence of direct attacks on health workers, ambulances, and obstructions to emergency health service providers.

However, these attacks mark a distinct departure from those seen earlier. As a consequence of the prevailing insecurity, thousands (including those in relief camps) are virtually cut off from routine medical services. In turn, they are dependent on temporary medical camps being run by civil society organisations and security forces, with serious ramifications for the future.

Unsparing and Ruthless Attacks

This is why we need to pay attention to the killings of 4 June 2023 where an injured semi-conscious seven-year-old boy, Tongsing Hangsing, his mother Meena, and their neighbour Lydia Lourenbam were being transported in an ambulance to the Regional Institute of Medical Sciences (RIMS). On the way, they were attacked, tortured, and burned alive in the ambulance by a mob in Iroisemba (Imphal). 

As reported, Tongsing was being transported for emergency care after suffering bullet injuries to the head. Tongsing’s father was a Kuki, while his mother was a Meitei. The third victim, Lydia, was also a Meitei. Apart from the fact the security escort from the Assam Rifles (under the operational control of the Army) was obstructed, the senior police official and policemen who tried to protect the ambulance were assaulted too. What is even more grievous is the fact that the violence was driven by a rumour that the ambulance was transporting an injured militant.

Ecological Warfare & Decentralisation of Violence

So, what does this tell us about the direction that the violence in Manipur is now taking? First, we see a new model of warfare emerging, whereby, traditional sources of restraint (especially at the community level) on both sides are being crowded out. This loss of the middle space can be gauged by the destruction of more than 230 churches and 17 temples in the first wave of violence. Despite several years of insurgency in the region, religious institutions until now, have more or less been excluded from direct attacks, and have played a significant role in community peace-building. 

Another disturbing trend is the emergence of ecological warfare at the micro-level. This includes systematic attacks on local water sources for villages in the foothills (despite inter-community level agreements that facilitated water-sharing), attacks on forest and grazing land, the burning down of agricultural land with standing crops, looting, and the killing of livestock. For instance, in the early days, even poultry farms were burnt down by unknown armed persons.

Consequently, there is an emerging crisis in agriculture and domestic food production; whereby the fields of those who are displaced are left unattended. Farmers seeking to return are vulnerable to gun violence and there have been instances of firearm injuries inflicted on herders as well.

Increasingly, the decentralisation of violence is becoming one of the gravest risks facing the state. The societal consequences of the looting of more than 4000 firearms and several thousand rounds of ammunition from the armouries of various state police forces are yet to unfold. This security challenge is further compounded by a pre-existing situation, where there already was a relatively higher proportion of licensed guns (for purposes of hunting). In a situation where firearms are now being circulated across all levels of society, the blow inadvertently will fall on the weakest and most vulnerable.

Refugee Crisis in the Northeast

What are the cumulative effects of these developments? The first and foremost is the occurrence of a massive crisis of forced internal displacement. While officially more than 50,000 people have been displaced and residing in formal/semi-formal relief camps within the state of Manipur, approximately 11,000 displaced persons are now residing in neighbouring states of Mizoram and Assam. Most recently, 1500 people fled to Nagaland. 

However, there is a high degree of underestimation of the number of people who fled their homes. Some individuals were living in the camps of the security forces. There is also an unrecorded population who have fled the state to various cities such as Dimapur, Shillong and Guwahati, and other parts of India.

Some relief camps have come up in locations as far as New Delhi. Another undercounted population is those who are moving towards safety. There are people who are still moving through various inner village roads, hiding in the jungles, or using forest tracts as well as escaping in private vehicles. It was recently reported that a 57-year-old man and his 23-year-old daughter-in-law who were fleeing the conflict were killed when their car fell into a gorge near Mizoram. Also severely injured were three minors aged one, seven, and fifteen respectively. 

There are very few estimates of the exact number of children in camps or in transit. Thus, there are reports of children being born in relief camps (where it is impossible to provide high-quality neonatal care) and of children dying in relief camps due to preventable illnesses. Preventable deaths are occurring among the elderly, who need special care and treatment. At least two cases have also emerged where elderly persons have died in camps due to the lack of access to dialysis machines and life-saving drugs.

Health Institutions as Neutral Spaces

It is becoming increasingly clear that the formal and informal blockade of access roads both into Imphal Valley and Hills is compounding the burden. It is further becoming a major source of grievance. The price of essential commodities and medicines is soaring for all communities. There is a serious shortage of water in Imphal and prices of water tankers have escalated. Without internet access and access to ATMs, payments for medicines and other essential items have been impacted. Remittances through digital platforms into Manipur have ceased. Conversely, those studying or working outside Manipur cannot receive money. This further aggravates an already charged political environment, leading to further outbreaks of extreme violence.

Especially in this situation, the only safeguard against firearm injuries, disease, epidemics, and mortality, is a fragile overburdened health system. A system that itself is under-resourced and just emerging from the pandemic.

Humanitarian organisations can only complement these efforts. It is in ensuring the continued functioning of the state-health system and the medical supply chain which is a sustainable short-term and long-term solution to mitigate the impacts. Since the outbreak of conflict, patients from the hills are avoiding valley-based health institutions and vice-versa. 

Health services in such emergencies, by their very nature, represent an institutional manifestation of shared universal humanistic values. They represent a higher ideal where life-saving care is provided to the most vulnerable regardless of social category.

In a multi-ethnic geography, the referral and patient transfer systems cut-across ethnic enclaves. An ambulance driver therefore is simply an ambulance driver and a patient is just a patient. A child with a traumatic brain injury is just a child who needs urgent emergency medical care. The mother and her friend accompanying him was just a grieving mother and an aunt who wanted to save him. 

The Need for Urgent Mitigation Measures

Some urgent remedial measures are, therefore, needed. First, the development of a temporary truce or humanitarian ceasefire among the conflict parties, whereby the dead bodies of those who were killed in the first wave of violence and are still in the morgues across districts, can be repatriated to their families. In addition, the release of those who have been abducted with information to be provided by all sides to medical authorities on locations of unretrieved bodies thus, enabling closure for the families. 

Second, the creation of clearly demarcated medical corridors through which critically ill patients, and injury victims (especially in the border areas, frontline zones, and relief camps across the state) can be transported safely for treatment to neighbouring states without interference. Third, the linking of these corridors to air-evacuation facilities and increasing medical evacuation flights (through the deployment of additional helicopters).

Fourth, a formal or informal commitment by all Civil Society Organisations, Armed Groups, Security Forces, and Community Based Organisations that no ambulance, student transport vehicle, health institution, or school will be attacked or damaged.

Fifth, coordination in relief operations between various state health services across the neighbouring states. 

There is a need for further ancillary linkages. The medical corridor should be kept open to students travelling outside Manipur availing education facilities or giving entrance exams. The ongoing total blockade that is occurring in Kangpokpi should have exemptions for patients and students.

Lastly, the lifting of the statewide internet ban, or the creation of a temporary state-wide weekly window for digital payments/UPI Transfers and online banking transactions and provision of video-calling and temporary banking facilities next to relief camps for those who have been displaced. In addition, unconditional cash-based assistance and market recovery programmes for the affected population. 

Embedding Peace in Healthcare

One of the most important aspects of the ongoing conflict is that community-level solutions do not necessarily require externally provided top-down templates. Creative networked solutions can evolve organically from within and are possibly more sustainable in the long run. It begins with those at the forefront asking whether this type of new normal is acceptable. Small, incremental, yet significant steps are now being made that need to be encouraged, supported, replicated, and sustained.

Thus, Shija Hospital and Research Institute (SHRI), one of the largest private hospitals in Imphal, recently declared that they will provide free medical care beyond ethnic lines to those who have sustained injuries as a result of the prevailing violence.  

Moreover, as a humane gesture, the medical expenses for the treatment will be borne by the staff of 1590 at Shija Hospitals, who will be providing their consultations to the victims and services free of cost. Food provided for patients will be free and eleven medical stores and a few companies will support this endeavour. Special helplines are being set up for victims. Manipur has, therefore, set an important precedent. It is important to note that in the early 2000s, a Health and Peace Programme was actually implemented in Senapati District on an experimental basis. It is, therefore, imperative that learnings from the present and past are harnessed for a better future.

(Dr. Samrat Sinha is Professor, Jindal Global Law School (JGLS), O.P. Jindal Global University (JGU)-Sonipat and Visiting Researcher at the Peace Centre (Chümoukedima-Nagaland). Fr. Dr. C.P. Anto is Founder and Principal, North East Institute of Social Sciences and Research (NEISSR-Nagaland), Founder Peace Channel-Nagaland and the Peace Centre (Chümoukedima-Nagaland). Deepanshu Mohan is Professor of Economics, and Director, Centre for New Economics Studies (CNES), O.P. Jindal Global University (JG). The authors thank Dr. Sunil Kaul, Founding Trustee- the Action Northeast Trust (the ant), Bodoland Territorial Region (BTR), Assam, on sharing his experience with the Health and Peace Programme in Manipur. The authors also acknowledge the kind contribution of Doctors for You-India-Northeastern RegionThis is an opinion article and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)