Imphal, Bishnupur and Churachandpur: 12-year-old Limkhopao is battling blood cancer. He cannot access treatment, because the only doctors who can treat him are on the other side of the border, within his own state – a man-made border, bristling with armed vigilantes, that blocks his community from accessing the life-saving treatment he so desperately needs.

Since May, ethnic clashes between the majority Meitei community and the minority Kuki-Zo community have unofficially split the north-eastern state of Manipur in two areas, with the Meites concentrated in the Imphal Valley and the Kuki-Zo community entrenched in the hills. Even after almost four months of strife, and despite over 40,000 security forces being stationed in the state as per data provided by the state government, violence continues to cost human lives.

According to official figures, over 190 people have been killed so far in the violence that started on 3 May this year. In a state with a population of around 2.7 million, more than 60,000 people, as per the state government, have been displaced and are now living in relief camps.

New borders, new war

With the Meiteis entrenched in the valley and the Kuki-Zo in the hills, unofficial but very real borders have sprung up to separate these two areas, and neither side can cross into the other's area, our reporting found. There is a four-layered security set-up involving the Indian Army, the Border Security Force (BSF), Assam Rifles, and the Central Reserve Police Force (CRPF). Behind these uniformed buffers, there are checkpoints manned by armed male and female volunteers on both sides.

The supply routes to the Manipur Hills traverse a buffer zone situated between these two communities. Here, reports of gunfire have become a daily occurrence, impeding the transportation of vital necessities, including medicines, from Imphal. As a result, a medical war is unfolding in the biggest district of the state, Churachandpur.

12 year old Limkhopao, with his mother, outside a relief camp in Churachandpur.
He is battling blood cancer, but cannot cross the new man-made border to access the care he needs.

Both tertiary government hospitals in the state are located in Imphal: the Jawaharlal Nehru Institute of Medical Sciences Hospital run by the state government and the Regional Institute of Medical Sciences Hospital run by the Centre. Top private hospitals such as Shija Hospitals and Research Institute and Raj Medicity are also located in the capital city, Imphal, where the Meiteis live and the Kukis cannot enter.

On the other hand, Churachandpur has only one district hospital, and the only medical college in 10 hill districts, as per the state government. There are four private hospitals, but these have no ICU beds or specialised doctors, thereby putting the entire load on the district hospital, which is overwhelmed with patients and reeling from a severe shortage of resources.

The rich flee, the poor die

Forty-six-year-old Vakhoneng and 67-year-old L. Chinkhanlian belong to the Kuki community. Both of them were stuck in the hill district of Churachandpur when the violence started, with severe illnesses and no access to treatment. Due to the unofficial partition, Imphal’s tertiary government hospitals were out of bounds for both of them. They were referred to Aizawl for better treatment, but due to the difference in financial resources, Chinkhanlian survived as he could cross over into the neighbouring state of Mizoram in a hired ambulance while Vakhoneng, who did not have similar resources, died.

"In July my mother was in a lot of pain as she had been battling stage 4 stomach cancer,” said Vakhoneng’s son, Thangjamang, speaking through his tears. “Churachandpur District Hospital referred my mother to the Aizawl Cancer Hospital due to lack of facilities at their centre.

“After our father died last year, my brother and I were somehow making ends meet by taking up labour jobs, but the violence took even that source of income away. We did not have any money to take our mother to Aizawl – the ambulance hire alone costs over Rs 50,000 because the government hospital does not even have ambulances to transport patients. She could have been treated in Imphal, but that door was closed for us Kukis. She died on 30 August and we are orphans now -- will the government take responsibility for this?"

Chinkhanlian, on the other hand, had been admitted to the Centre's Regional Institute of Medical Sciences (RIMS) in Imphal before the violence started. He had a second stroke in July. His family hired a private ambulance from an Aizawl hospital for Rs 80,000, which took them from Churachandpur to Aizawl. From there, they flew to Guwahati, where he was admitted to a private hospital and then to Guwahati Medical Hospital. All told, his family spent over Rs 10 lakh on his travel and treatment.

"The right side of my father's body was partially paralyzed after the first stroke in 2022,” Chinkhanlian’s son, Langzachin, told IndiaSpend. “When he had a second stroke in July, his condition worsened. We immediately took him to the district hospital, but they did not even have the medicines he needed. They referred him to a tertiary care centre in Aizawl or Guwahati, and we did not waste a single second. My father runs a newspaper in Manipur and because of our connections, a private hospital in Aizawl sent us an ambulance which took my father to Aizawl airport. We are lucky to be privileged -- I can't even imagine what the less privileged are going through".

32-year-old Lamneichong Haokip and her 15-year-old daughter now sell vegetables to stay afloat. Her husband, a government worker in the Sericulture department under the Manipur state government, died in July this year. After both his kidneys failed in 2021, he was undergoing dialysis at the Jawaharlal Nehru Institute of Medical Sciences (JNIMS) in Imphal. But after the violence broke out, his father was brought back by the security forces to his village, DM Veng in Churachandpur, in the first week of May. When he went to the district hospital in May, one of the nurses was shot in front of his eyes and he somehow managed to escape. That same day, Meitei dialysis technicians left the area.

"I remember taking my father to the district hospital in June last week. The doctor said that two of their dialysis machines had stopped functioning properly and one had no one to man it,” 15-year-old Hoimgaithem recalled. “They referred him to JNIMS in Imphal for a kidney transplant, or to Aizawl. Despite being a government employee, he did not get any help, and even before we could arrange to take him to Aizawl, he passed away due to not taking dialysis. I am in class 10 but I have three younger siblings and a frail grandmother. So I had to leave studies to help my mother sell veggies -- otherwise, what are my siblings going to eat?"

Lack of everything, including government

Kuki men, who are college students, guarding their self-made border with rifles. The new borders in Manipur state means patients who need to cross over to access healthcare cannot do so.

The Chief Medical Officer of Churachandpur has been going from pillar to post to arrange for medicines and essential equipment for the district hospital. Speaking to IndiaSpend, CMO Dr Vanlalkungi says, "We are facing an acute shortage of medicines, especially those meant for dialysis patients, TB [tuberculosis], cancer, HIV, hypertension, seizures, and paralysis etc. These are life-saving drugs.

“Even doctors have become a luxury,” the CMO said. “Out of 60 specialists and medical officers in the hospital, 16 were Meiteis who had to leave the district. Even our dialysis technicians left, making the dialysis centre nonfunctional for days. Now, we have just one technician taking care of 26 patients on just four machines. Even if we can get doctors to come from outside the state with the help of NGOs [non-governmental organisations], without essential drugs they won't be able to save lives."

Even money for fuel for the few ambulances that are available is through donations by civil society organisations and NGOs. "Zero funds have been sanctioned by the state government for the local purchase of medicines, or for bringing in medicines from other states,” Dr Vanlalkungi says. “Doctors and individuals have been paying for essentials from their own pocket. We have just eight ambulances across the district, which has nearly 300,000 population now. Even for fuel, we begged the government, but no help has come so far. I requested a senior health officer in the government over a phone call in June about the urgent need for funds -- he said that he could only give Rs 50,000, but unfortunately even that money never came."

There is a critical shortage of nearly everything, Dr Vanlalkungi points out. "Since May 3, we have received seven consignments of medicines and other essential drugs for Churachandpur -- thrice by chopper and four times by road in Army vehicles. Each consignment just had one carton of 5 kgs – sufficient for two or three relief camps. But we have to cater to a population of approximately 3 lakhs. The worst affected are the bordering villages which have no access to any healthcare. Most of the PHCs [primary healthcare centres] are shut due to lack of doctors and nurses, so we have sent one medical officer and a nurse to all the bordering villages of the district."

The Churachandpur district hospital does not have a single super-speciality doctor. The staff of 44, including general physicians and specialised doctors, have been working around the clock since 3 May without taking a single day off.

Patients with serious bullet injuries had to be transported to Aizawl, as the Churachandpur hospital did not have a cardiothoracic surgeon. The Churachandpur District Hospital was granted a medical college, but it fails to meet the minimum standard requirement to be one, as per the deputy superintendent of the district hospital. A C-arm machine required to detect foreign objects in the body is non-functional. The hospital does not even have an incinerator to dispose of biomedical waste.

Deputy Superintendent Dr Seinboi told us, "Conditions are worsening. We just have one CT-Scan machine, one ultrasound, one X-ray machine, and just one radiologist to man all of them.”

A district hospital official, who did not want to be named, told IndiaSpend that funds of Rs 10 crore under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) scheme, and the state health scheme, which the hospital is supposed to get, are still pending.

“The problem,” Seinboi said, “is that the government expects scarce doctors to provide services for free, arrange everything on our own, and depend upon NGOs even in such dire situations. Earlier, we used to collect our stock of medicines from the state centre in Imphal, but since the conflict started, the supply has been completely shut.”

The violence in the Imphal Valley is mostly under control, but even the biggest tertiary hospital, JNIMS in Imphal, is running out of medicines. The director of JNIMS, Dr T. Rajen Singh, told IndiaSpend, "We do not have a shortage of doctors but even we are running out of essential drugs like those needed for blood pressure, diabetes, and even cancer. We used to get most of our supplies from Guwahati. Ever since the violence, many essential highways have been blocked. And even after our several requests to the government, medicines have not been airdropped even once till now.”

“We have much-needed hospitals here in the valley -- otherwise, if the valley had to depend on JNIMS, the situation would have been very bad. We have written two letters to the government to ensure enough availability of medicines, but the government has not replied to any of our letters and has not even come up with any concrete solution for us. We haven't seen any casualties so far due to shortage of medicines, by god's grace, because we are managing medicines from other hospitals in the valley."

IndiaSpend has reached out to the health department in Manipur, but is yet to receive a response on the medical crisis unfolding in the state. We will update the story when we receive a response.

Disease and death in relief camps

There are nearly 115 relief camps in the hill district of Churachandpur, accommodating over 22,000 internally displaced persons (IDPs), as per civil society organisations that are looking after the camps. All these camps have been set up by civil society organisations like the ITLF (Indigenous Tribal Leaders Forum), KKL (KUKI KHANGLAI LAWMP), etc. According to these organisations, there have been over 50 deaths so far due to diseases and illnesses, out of which at least 35 died due to a lack of medicines, poor living conditions at relief camps and access to proper and timely treatment.

A 62-year-old ex-serviceman, Lunkhothang, who had served in the Assam regiment has been waiting alongside his wife's stretcher for the last four months. They live in a church-turned-relief camp in Churachandpur district. His wife is suffering from a brain aneurysm triggered when multiple veins inside her brain exploded, and has been paralysed since last year.

She was getting better in Imphal's Shiza hospital, where she was admitted to the Intensive Care Unit (ICU) till May this year. After the violence broke out, she was brought into the relief camp by an Indian Army convoy. Now she lies there, corpse-like, in a bed with no machines, treatment or medicines, with just a catheter attached to her. She can only be fed through her nose. For the first week of violence in May, her family didn't even have the powder to nose-feed her -- they had to keep her on just water, which worsened her condition.

Her daughter, Deborah, tells us, "There is no neurosurgeon at the Churachandpur district hospital. The medicines she was given at the hospital in Imphal – we asked an NGO to help us with those. We do not know for how many days she will survive; we cannot see her suffer anymore; we cry every day that we cannot do anything to make her condition better."

Mariah, with her two sons, in a relief camp in Churachandpur, Manipur, after burying her youngest son, who died because he did not get medical care in time.

The smallest coffins are the heaviest. For 48-year-old Mariah, it felt like her world came crashing down when a nurse at the Churachandpur district hospital told her that her two-year-old son was dead.

On July 6, both her sons woke up with high fever. The family gave them medicines made available to them by health camp volunteers. In the next two days the elder son, who was six years old, developed pox-like boils on his body; the two-year-old son also had pox, but the boils did not show.

The family took both children to the district hospital, but it was overflowing with patients. So the family took the kids to a private hospital -- but since they lost all their money when their house was burnt down in the violence, they had no way of paying for treatment.

They brought the kids back to the relief camp. This, Mariah says, was her biggest mistake. "Many children were falling sick in the camps during June and July. Some had malaria, some had encephalitis. I thought my sons would be fine soon. I stayed up all night taking care of my children, giving them the medicines given to us by the local pharmacy.

“After three days my six-year-old started recovering, but my two-year-old's condition was not improving. On the fifth day, when his condition worsened, we immediately called volunteers from the civil society organisations. They took my son to Churachandpur District Hospital in their vehicle. As soon as we reached there, the nurse checked his pulse and declared him dead.

“It felt like my heart would stop beating,” Mariah sobs. “This would have never happened in a normal situation. The clashes have ruined our lives completely. We lost our home, our children, everything, and the government has been silent for the last four months while the poor are dying and suffering beyond imagination."

Forty-seven-year-old Maisanam Lata, with her 2 daughters and handicapped husband, in a relief camp in Bishnupur.
The medicines for her rare heart condition are available only once in two months at the district hospital, and that, at too high a cost for the family.

Churachandpur is one of the worst-hit regions in the violence, but the ordeal is no different in the relief camps on the Meitei side of the border. Forty-seven-year-old Maisanam Lata, who lives in one of the 58 relief camps in Bishnupur district with her two daughters and a handicapped husband, suffers from a rare heart condition. Her pain keeps her up all night. She goes to the Bishnupur district hospital every day, to no avail – each time, she learns that the medicines she requires are still not available. When they do become available, about once every two months, it costs her Rs 1,500 for a month’s worth of medication -- which she cannot afford as her house, and all her money got burnt down, back in the Churachandpur district.

"Doctors at the Bishnupur district hospital told me that I can only be treated at the Sky Hospital in Imphal and surgery could cost over 15 lakhs. The relief camp gives us some basic food but cannot cover the cost of medicines and treatment, I am waiting to die,” Lata says. “I was referred to Sky Hospital by JNIMS for surgery in March, but by the time I saved some money, violence struck and now I do not have any hopes left for my survival. I just want my daughter to get treated – she has a cyst in her left breast. She cannot be treated in Bishnupur, and since we are displaced, we cannot take her to JNIMS every day."

Loopholes in state healthcare

Churachandpur district hospital overwhelmed with patients.

While the ongoing violence has created a dire situation on both sides of the ethnic divide, the state of healthcare in Manipur was suboptimal even before the conflict began.

Manipur has 16 districts, out of which 10 are hill districts. The hills occupy almost 90% of the state area, but the Valley, with just 10% land, is home to almost 60% of the people. The residents of the hills say the area is neglected by the state government, which is headquartered in Imphal.

The budget for Manipur’s Health and Family Welfare department increased 10% in 2023, when compared to 2022, as per an analysis by the Centre For New Economic Studies at OP Jindal Global University, shared with IndiaSpend.

But few people have health cover in the state. In 2019-21, when the latest National Family Health Survey was conducted, 14.2% of households had any member covered by a health insurance or financing scheme in Manipur. This is lower than the national average of 41%.

These figures indicate that a majority of Manipur's population pays for medical expenses out of their own pockets, leading to financial burdens and challenges in accessing quality healthcare.

In 2017-18, as per the National Sample Survey Office’s report, the average medical expenditure per hospitalisation in private hospitals was Rs 49,784, seven times that in government hospitals, where it was Rs 6,944 per hospitalisation.

Manipur also has the highest prevalence of HIV among the adult population in the country, with a rate of 1.15%, compared to the India average of 0.34%, indicating a significant public health challenge in the state.

These numbers, taken together, point to an existing lack of healthcare infrastructure in the state – which has now been exacerbated, to critical levels, by the unending conflict.

We have not heard back from the government in response to our questions on the state of healthcare in Manipur. This story will be updated if and when we receive a response.

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