After the February 1 coup rocked Myanmar from whatever semblance of normalcy had survived the pandemic, the ongoing Covid-19 outbreak there has faded from the spotlight.
“Now for the public, covid is no longer an interest or threat,” one Yangon-based physician wrote to the Globe in a self-deleting text message, a style of communication that has become the norm among those wary of military eyes. “The more important thing is how to survive in daily life under the coup, how to take money out from the bank/atm etc. There are some new cases here and there but no concrete data.”
That’s in large part due to the body blow dealt by the coup to the Covid-19 response, which had strained under two waves of viral infection that killed more than 3,100 people before fracturing amidst targeted military crackdowns on key health officials and massive health worker strikes. With medical staff joining the ongoing Civil Disobedience Movement (CDM) opposing the coup en masse, many hospitals and clinics have been brought to a standstill.
This has led some outside medical experts to conclude Myanmar’s health system has largely buckled under the weight of political dysfunction, most likely enabling a simmering outbreak of Covid-19 to spread mostly undetected.
“The presumption is we have Covid running rampant, but we don’t have any systematic surveillance of morbidity and mortality,” said a different physician working with a foreign-backed health observation post. “There is no healthcare system to overwhelm. The healthcare system isn’t functioning.”
On January 31, the day before the coup, Myanmar health officials logged 281 new cases of Covid-19 on a rolling, seven-day average of 367 new diagnoses per day. Over the following days of increasing chaos across the country, the announced number of new cases whipsawed from zero into the hundreds, reaching as many as 573 on February 3 before settling in the tens, where it’s since held steady. Since the coup, authorities have announced fewer than 100 new Covid-19 deaths.
By any metric, the military-led response to the outbreak has dialed back since the coup. Even still, Dr Khin Khin Gyi, the head of the Ministry of Health and Sport’s infectious disease department and Covid-19 response spokeswoman, diagnosed the country’s situation as “slightly stable” while describing the changes in official public health strategy since February 1, omiting any reference to a change in government.
“In recent situations, there are more than 50-60% of health staff resuming activity, their work,” Khin Khin Gyi told the Globe. “We are not doing full capacity, so maybe slightly deficient in some parts, especially some major hospitals we can’t reopen yet.”
Though the spokeswoman said some township hospitals remain relatively full, the system overall is touching far fewer patients than it did prior to the coup, especially in terms of Covid-19.
“Our testing capacity is lower than it was previously, when it was 15-20,000 per day,” Khin Khin Gyi said. “Now, for testing we have only 1,500-2,000.”
As the test numbers have dwindled, recent months have also seen Myanmar’s rate of positive tests sharply decline. On May 23, the MoHS announced just six new cases of Covid-19, a number that would be reassuring if believed to be truly representative of the situation. Khin Khin Gyi said that wasn’t likely, pointing to low testing numbers and tightly packed street protests as possible vectors for transmission.
“Due to the crowds, generally we can expect more cases. But right now, the cases – some days we’ll see more than 30, other days less than 10. We cannot say this is the real figure of the recent situation,” she said.
“If we can test more than that, we’ll detect more than that. This is the general rule, so we are now trying to expand our testing capacity.”
By now, anyway, there don’t seem to be reports of mass mortality shared through social or conventional media, as has been seen elsewhere in the world where Covid-19 has taken root.
For Dr Rose Skalicky-Klein, an Australian emergency medicine physician who has been helping to develop the field in Myanmar for more than seven years and was supporting the Covid-19 response in-country until just before the coup, this doesn’t necessarily mean that deaths related to the virus aren’t happening in plain sight.
“You might not be seeing the deaths, but many deaths weren’t necessarily due to Covid respiratory illness,” Skalicky-Klein told the Globe.
As many public facilities remain closed or at minimal capacity due to the CDM, the Australian doctor said people seeking treatment are left either to go to private, military or charity hospitals. She added that patients are often afraid to go to military-run centres and, while private hospitals typically staffed with moonlighting public doctors have picked up some of the slack, their rates can still place them beyond the means of most in Myanmar, even after discounts. Security forces have targeted some charity hospitals for arrests of both doctors and patients, Skalicky-Klein continued, and it hasn’t been unusual to see soldiers stationed outside their doors.
The net result of this is that fewer patients are showing up in the health system at all, slashing any useful information on the deaths now happening in Myanmar. Without that broader data on mortality, Skalicky-Klein said it’s almost impossible to know what can be attributed to Covid-19.
“It made comorbidities worse, so people might have died from their kidneys failing, heart disease – it made those things worse, and they died. As well as people with respiratory cases, they were the ones that tended to get the media, the pure Covid. But to actually see Covid deaths, you’d have to look at overall mortality and you don’t have that [in Myanmar] either.”
Alternative methods to gauge excess mortality, such as examining burials or cremations, produced an unclear picture even in the months before the coup. In Yangon, an epicentre of the outbreak, the final handling of human remains is, for Buddhists, handled by a state office which has yet to release data on the caseloads it’s receiving.
Some said it is the heat/hot season, and some experts estimated that another wave will come back in the rainy season. But all are anecdotal
The same physician in Yangon, who sent self-deleting messages and asked not to be named, said that while public interest in the virus has waned, so too have serious explanations for where it has gone among the population.
“Some said it is the heat/hot season, and some experts estimated that another wave will come back in the rainy season,” the physician wrote. “But all are anecdotal. The information and health education messages on covid from the [new junta] is a lot less now. They took down previous health messages from the billboards, television, radio and other social media.”
People being tested now are mostly those who are showing symptoms of Covid-19 or have been identified as having a possible exposure to the virus, as well as those who require a test for international travel or work requirements. But Khin Khin Gyi also said doctors can’t properly conduct tests in some parts of the country, especially the PCR lab testing used as the most accurate and reliable mode of screening.
However, she added that PCR capacity is now coming online in the city of Mawlamyaing and was optimistic that by the end of the May the same would be true for Mandalay. That same timeline could also see new genomic sequencing of the virus, a process of unravelling the viral genetic code to identify its specific variant, permformed through military lab facilities in Yangon.
Myanmar health officials last conducted genomic sequencing of viral samples in January to determine which variants of Covid-19 were actively infecting people in the country. At that time, they found nothing especially alarming, detecting viruses of the “GH” group that had been common in Europe at that time. But since then, the more-contagious B.1.1.7. variant, also known as the UK strain, has driven serious outbreaks throughout the Mekong region, and Khin Khin Gyi said some recent incoming people on an aid flight from India had tested positive for an as-yet unidentified strain of Covid-19, raising fears of importing the variants currently ripping through that densely populated subcontinent. The spokeswoman said Myanmar has since blocked travel from India as a preventive measure.
As a public face of the Covid-19 response who has consistently said the outbreak response should transcend politics, Khin Khin Gyi is one of the more prominent health officials to remain in her post through the coup.
The spokeswoman took care to avoid political interpretations when discussing the outbreak, a tactic which has become essential for state employees still on the job. Through the nearly four months since the coup, many of her peers have either been pushed out of sight or into the opposition for refusing to do the same.
A little more than two weeks after the coup, a group of mainly Burmese doctors with two longtime Australian colleagues – including Skalicky-Klein – published a letter in the medical journal The Lancet sounding an alarm for the state of the medical field after the coup, arguing the Covid-19 response would be lost amidst the military’s brutal consolidation of power.
“Until recently, our busy public emergency departments were performing screening, testing, and early critical care for patients with COVID-19,” the statement read. “Since the military takeover, the COVID-19 response has stalled.”
The authors of the letter counted some of the most recognisable names in that response as it was before the military takeover. This included Dr Maw Maw Oo, the director of Yangon General Hospital arrested while on duty April 12. The emergency medicine physician had remained in his role after the coup in a bid to stay above the fray of political discourse and served as the emergency clinical lead for Myanmar’s national and regional Covid-19 response. Since his arrest, he is reportedly being held in Insein Prison, likely for treating protesters wounded in the military crackdown on dissent, as well as his association with another author of the letter, Dr Zaw Wai Soe.
Zaw Wai Soe took a different angle on the political situation once the Tatmadaw seized control of the state. The former rector at University of Medicine 1 in Yangon and the vice-chair of the committee overseeing the Covid-19 response in the commercial capital, he was an early booster of the CDM, joined the boycott of public institutions when it began and went into hiding as a vocal member of the resistance. By the start of this month, the doctor had been named as the first minister of health and education of the National Unity Government (NUG), the civilian leadership formed by a core of officials ousted by the coup.
Though he didn’t respond to requests for comment, his longtime colleague Dr Georgina Phillips, the other Australian author of the Lancet letter, told the Globe the loss of key personnel and facilities has plunged the Covid-19 response into uncertainty.
“It’s pretty impossible to get information now,” Phillips said. “There’s not really a public health response, except for the military. A lot of people who were working on it before, some were targeted specifically [by the military] after the coup.”
Transferring the bulk of positive patients to a Covid-designated facility, that’s not happening at all, the hospital is barely operational
Phillips first met both Zaw Wai Soe and Maw Maw Oo in 2009, when she went to Myanmar to provide training in emergency medicine, her clinical specialty, in the wake of Cyclone Nargis. She would go on to work with both men from 2013 until the coup, developing emergency medicine in Myanmar in close collaboration with local doctors, many of whom would play key roles in last year’s outbreak control measures.
The past few months, Phillips said, have seen a sharp unravelling of those measures.
“Certainly now in Yangon, the hospital response is not happening. Yangon General, which was the main centre and extremely well set up for testing, triage, clinical care and then transferring the bulk of positive patients to a Covid-designated facility, that’s not happening at all, the hospital is barely operational,” Phillips said, recounting conversations she’d had in past weeks with colleagues and other medical workers.
Despite the weight of the CDM on the chest of the health sector, spokeswoman Khin Khin Gyi said the MoHS is focused on getting through the next three months of whatever the outbreak will throw at Myanmar.
“We have the budget for the healthcare system so we’re not much worried about it,” she said. “If we face another wave, we can handle this situation up to treatment, we have the logistics, stocks, equipment.”
So far, the MoHS has helped oversee the full vaccination of nearly 1.75 million people against Covid-19, Khin Khin Gyi said, and has so received enough doses of serum from India to fully vaccinate another 1 million people on a two-shot regimen. The ministry is also expecting to obtain still more innoculations from India to cover 750,000 additional patients in Myanmar, as well as enough doses of the Chinese-made Sinopharm to vaccinate 250,000 people.
With a national population of more than 54 million, Myanmar’s health authorities will need to vaccinate at least 32.4 million people to begin reaching the lower bound of what epidemiologists regard as achieving “herd immunity”, a prospect seen as unlikely even in more developed countries.
Unless the critical nodes of the health system can be brought back online to detect the outbreak as it’s happening, the surge of mortality could slip undetected past much of the medical community — and into Myanmar households, killing through any number of preexisting conditions.
“Many people are not going to government hospitals, or the military hospitals, so there will be a lot of data that we’ll have to wait for years before knowing what really happened,” Skalicky-Klein said.
