Myanmar faces COVID-19

As the coronavirus pandemic has unfolded across the globe, it has exposed the weaknesses in public health systems, and has also encouraged acts of resilience and resolve in implementing measures to slow the spread. Dr Joanna Barnard looks at the current situation in Myanmar and reflects on the challenges facing the country as it balances the welfare and livelihoods of its populace.

April in Yangon is normally a riotous and joyful time. Thingyan marks the coming of the New Year, celebrated by water throwing, dancing, music and performances. Full of colour, the festival is a time for family and friends to come together and enjoy the most significant public holiday in Myanmar’s calendar. This year, however, is different. The streets of Yangon are quiet and almost deserted, as Myanmar, like so many other nations worldwide, responds to a new public health threat: COVID-19.

Existing Public Health Infrastructure

Myanmar is no stranger to novel infectious diseases. Since 2006, multiple rounds of the H5N1 virus, otherwise known as ‘bird flu’ have been recorded. H1N1, commonly known as ‘swine flu’, has also broken out annually since 2009. Similar to seasonal flu, H1N1 was declared a pandemic by the World Health Organisation (WHO) due to its rapid spread worldwide, and continues to claim lives in Myanmar.

Myanmar’s Department of Public Health is administered under the Ministry of Health and Sports (MoHS). Its Central Epidemiology Unit is the national focal point for the surveillance of and response to communicable diseases. Its main function, according to government literature, is to become the “nucleus of the future Myanmar CDC”.  As Elliot Brennan argues in a 2017 Tea Circle article, the response to H1N1 highlights how far Myanmar has come in health communication and cooperation.

Government Response to COVID-19

One day after the WHO declared the coronavirus outbreak to be a global health emergency, the President’s Office announced the formation of a special committee to tackle the crisis.  By February, the government was conducting a screening process at international gateways and hospitals,  and MoHS labelled COVID-19 an “epidemic or notifiable disease”.   However, concerns were raised over reporting, as until as late as 16 March, while China was reporting some 80,000 infections, Myanmar had not recorded a single case of coronavirus, despite sharing a porous 1,400-mile border.

Since the government confirmed its first cases, it has increased measures to prevent the spread. Public gatherings and events have been cancelled, airports closed, and additional restrictions have been placed on internal travel. A variety of measures have been taken in townships across the country, but a lack of centralised policy has affected coordination.

Measures in Yangon have been stricter, with the Yangon Regional Government issuing orders for venues such as cinemas and clubs to close, and for Yangon’s normally bustling restaurants and teashops to offer takeaway-only service. While most have complied, some have flouted the rules, due to a combination of a lack of enforcement and concern over the financial implications of an indefinite period of closure.  Businesses have been encouraged to apply for loans from the government, which has set up a K100 billion fund to support businesses affected by COVID-19. In Yangon, a lockdown was ordered in mid-April, during which time the regional government advised people not to leave their homes except to buy food or receive medical care.

Information on COVID-19 has been disseminated in various languages by MRTV, Myanmar’s national television service. Government advice on social distancing is available on the MoHS website, and an online dashboard publicises the latest figures. However, testing rates remain extremely low, and at present only one laboratory in the country has the capabilities to test for the disease.

Will Myanmar face a public health emergency? The picture is a complicated one, even for seasoned epidemiologists, and depends upon several interlinked factors:

Socio-Economic Challenges

Myanmar has a large informal workforce without access to state support.    Workers are often paid cash-in-hand and have no employment contracts; in consequence, measures taken to curb the spread of the virus may leave many in a precarious situation.

For formal workers, an undeveloped welfare state is only able to provide limited support.

A relatively small service economy means that few can work from home, and instead face pressure to continue to commute to maintain their income.

Many people live in multi-generational households, often with elderly relatives, and living and sleeping spaces are shared. Self-isolation is therefore only possible for the most affluent.

Conflicts continue in several ethnic borderlands where there are up to two million internally displaced persons (IDPs) and refugees. In these territories, there are many concerns that the virus could spread unaddressed (see article: A Land in Health Crisis).

The movement of migrant workers took the government by surprise. As cases rose in China, many workers chose to return home, and similarly as Thailand closed its borders in late March many thousands of Myanmar workers rushed to return to villages across the southeast. The impacts of closures, lockdowns and generalised uncertainty can also trigger mass movement, all of which have the potential to spread the virus further as quarantine measures were not in place for returning workers, and are furthermore difficult to enforce.

Early studies have shown that smoking heightens risk for those who contract COVID-19; smoking and chewing betel are well-established practices in Myanmar and may exacerbate symptoms.

The country suffers a high burden of malaria, tuberculosis, HIV and other serious diseases, and a major spread of COVID-19 would have a severe impact on an already-stretched medical system.

Medical Infrastructure Challenges

With underdeveloped primary, secondary and tertiary care, disparity in access between urban and rural communities, and significant gaps in service delivery for many ethnic groups, it is possible that the virus will highlight existing inequalities in health provision.

Myanmar has a total of 586 critical care beds, an average of 1.1 per 100,000 population, giving it the second lowest critical care capacity in the Asia region.

It has been suggested that there are only 200 ventilators for a population of over 55 million.

The country suffers a high burden of malaria, tuberculosis, HIV and other serious diseases, and a major spread of COVID-19 would have a severe impact on an already-stretched medical system.

Mitigation

At the time of going to print, the reported incidence of the virus in Myanmar has been low. The government is cooperating with the WHO and other international organisations and is accepting overseas assistance.    The latest data has shown that the virus disproportionately affects the elderly. In Myanmar, only 5.5% of the population is over 65, compared to 18% in the UK.

There is also uncertainty over the spread of the virus in tropical countries. Writing in Frontier magazine, Dr Frank Smithius, former director of MSF Myanmar, noted that COVID-19 has a different, and crucially much slower, transmission dynamic across Southeast Asia compared to China, Europe and the United States. He argues that this ought to inform a tailored set of preventative measures, which focus on social distancing and hygiene rather than a full lockdown, which could have a huge impact on livelihoods. Jordan Tun further argues that a lockdown, implemented by the Tatmadaw (armed forces), could represent a step back for Myanmar’s relatively new civilian government.

There remain many reasons for caution. COVID-19 has proven a difficult crisis in many countries around the world. In Myanmar, epidemiologists are watching for the ‘flu season’ (June-September) when virus challenges usually spread within the country. In the meantime, civil society organisations are urging that health outreach is made available to the most vulnerable and at risk.    To celebrate Thingyan, the government released 25,000 prisoners, which reduced health pressures on the country’s crowded jails. But vigilance will remain essential in the coming months if the country is to avoid the WHO’s worst predictions of a global pandemic.

Outlook

Given the particular risk factors in Myanmar and the need to protect both welfare and livelihoods, the COVID-19 response comes down to a question of responsive management. Mitigation methods must be flexible and open to review, evidence-based in relation to techniques employed elsewhere in Southeast Asia and in the wider Asia region, and supported by the international community.

Measures must be accompanied by effective information campaigns targeted to specific groups in a variety of languages, to counter misinformation. As Sithu Aung Myint comments, a bond of trust between the government and its people is vital in ensuring that people understand and comply with public health requirements.

For Prospect Burma, it reminds us that our work is as important now as it ever has been – continuing to work to support young people in their education pathways, so that they may return and help develop Myanmar and encourage the kind of resilience and resourcefulness that is needed to address these challenges that we all face in this complex 21st century world.

To read the article with full citations and links, please read the article in the Health Newsletter