In this blog, Yu Nandar Aung discusses the health crisis in Myanmar, following the military coup in February 2021. Like with previous public health emergencies, the author highlights their potential to affect neighbouring countries and outlines what this means for regional and global health.
On February 1, 2021, the Myanmar military staged a coup d’état by overthrowing a democratically elected civilian government. Since then, the military has killed at least 870 people and unlawfully detained more than 5,000 people as of June 21, 2021. Health care workers and health facilities became the targets of the military’s indiscriminate attacks. Within five months, World Health Organization (WHO) recorded 220 attacks on health care personnel/facilities in Myanmar, which resulted in 14 deaths and 53 injuries. The military has taken base at hospitals and issued arrest warrants for over 400 doctors and 180 nurses for their participation in a civil disobedience movement against the coup. To avoid arrest, medics participating in the strike cannot practice openly, in private or in nonprofit clinics. Most are forced to provide health care in make-shift locations. Myanmar’s health system, already crippled by the COVID-19 pandemic, is on the brink of collapse.
Learning from history
During conflicts, history has seen the proliferation of health emergencies that do not respect national boundaries. Two prominent examples are the polio outbreak that emerged in Syria and the Ebola outbreak in the Democratic Republic of Congo (DRC), which were both declared as a Public Health Emergency of International Concern (PHEIC) by the WHO in 2014 and 2019, respectively. What’s striking is these two public health emergencies were borne out of conflicts and were 2 of total 6 PHEICs declared by WHO since the International Health Regulations (IHR) became legally binding for WHO member states in 2007.
Due to attacks on health care workers/ facilities and collapse of the health system during the Syrian civil war, childhood immunisation activities were drastically hampered. Subsequently, polio re-emerged after 2 decades of having the eliminated status in Syria. Within 5 months after the re-emergence in Syria, the polio virus reached neighbouring Iraq, which had not had a polio case for 14 years. Due to the continuous low coverage level of polio vaccinations amidst civil war, Syria had a 2nd polio outbreak in 2017, which lasted for 1.5 years until it was controlled. Similarly, the Ebola outbreak borne out of armed conflicts in the DRC evolved into the 2nd largest Ebola outbreak of the history. The virus was exported to its neighbour, Uganda, which was able to prevent secondary infection only because of its strong surveillance system. The Ebola outbreak in DRC lasted for 2 years, ending only in June 2020. In both Syria and DRC’s public health emergencies, studies have shown an association between violence or political crisis and increased disease transmission, which in turn disrupt access to health care.
Whether or not Myanmar can become the next source of an international public health emergency cannot be ruled out. One cannot ignore some parallels between Syria or DRC and Myanmar in terms of systematic attacks against healthcare and a collapsed/fragile health system. Since the coup, UNICEF Myanmar has already started seeing a disruption of childhood immunisation activities. Although Myanmar was declared polio free since 1996, there is always a risk of wild-type polio virus importation from other countries or an outbreak of Vaccine Derived Polio Virus (VDPV) once the polio immunisation coverage becomes low. There might also be new threats to regional or global health stability, for instance by diptheria or measles, since the coverage for all types of childhood vaccines are shown to be low in conflict-affected areas. If polio or any vaccine preventable disease (VPD) outbreaks happen in Myanmar, its neighbours will find themselves in vulnerable positions. This is especially true for countries that have low national immunisation coverage or heterogenous immunisation coverage across different geographies.
Since the coup, UNICEF Myanmar has already started seeing a disruption of childhood immunisation activities
Polio or VPD will not be the only threat for the region. Control of infectious diseases, particularly the ones that demand regional approach for interventions, will soon be in jeopardy. For instance, Myanmar together with other countries in the Greater Mekong Sub region (GMS) are aiming to eliminate malaria by 2030. The region’s malaria cases declined dramatically by 90% between 2000 and 2019. A remarkable investment has been made by the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) by investing more than half a billion USD since 2014 towards regionally coordinated malaria elimination in the GMS. All these investments, achievements and regional aspirations for malaria elimination will be at risk of failure if health care delivery continues to be disrupted in Myanmar.
Addressing emerging regional health threats
If a polio or VPD outbreak may seem remote and malaria elimination goal may not be appealing enough to engage the regional partners, the COVID-19 pandemic indicates otherwise. It is undoubtedly an acute problem that is threatening the whole region. After the coup, the COVID-19 situation in Myanmar has gone down a death spiral. The number of testing which averaged around 18,000 a day before the coup, has reduced to less than 1,500 a day after the coup. The COVID-19 vaccination rate is also lagging far behind the rate intended by the pre-coup government. Since the last week of May, increased numbers of COVID-19 cases and deaths were reported in Myanmar. In mid June, the military-controlled health ministry announced the detection of COVID-19 variant B.1.617, that is believed to be causing rapid spread of infection in India. Although there is skepticism with the credibility of the information released by the junta, it is within reason to believe that B.1.617 variant is already in Myanmar since 4 out of 5 countries that are bordering with Myanmar have reportedly found the variant and cases in Myanmar are increasing rapidly despite very low testing rate.
This indeed is a dire situation for Myanmar since its health system is rapidly deteriorating following the coup. As we have seen so far with the global COVID-19 pandemic, the problem in Myanmar will definitely spill over to other countries. For its neighbours, protectionist approaches of shutting down borders will not work since conflicts in Myanmar are driving people out of the country through every possible porous border. National vaccination campaigns will also take time, and it might not even solve the problem because commonly used vaccines in the region (e.g., AstraZeneca, Covaxin) are found to have lower efficacy against B.1.617. After all, viruses know how to survive, and there is a chance that Myanmar will become an exporter of virulent COVID-19 strains to other countries and perpetuates the pandemic.
After the coup, the COVID-19 situation in Myanmar has gone down a death spiral. The number of testing which averaged around 18,000 a day before the coup, has reduced to less than 1,500 a day after the coup
Even if it is not for political interest, international partners should not ignore the humanitarian disaster in Myanmar that poses a threat to the region and warrants multidisciplinary approach from different partners. The United Nations (UN) could do more in terms of advocacy and actions. UN security council resolution 2286 stipulates the UN Secretary General prerogatives as well as States’ responsibilities in prohibiting violence on healthcare and bringing perpetrators to account. Regional partners such as the Association of Southeast Asian Nations (ASEAN), India, China, and Bangladesh also have a big role to play in both advocacy and providing humanitarian support. The 5 points consensus that ASEAN member states agreed in April 2021 should be materialised sooner and extended to emphasise the need for support in the Myanmar healthcare crisis.
Donors and development partners should also take a flexible, responsive, and holistic approach in providing humanitarian assistance that can swiftly adapt to the rapidly evolving situation. Although accountability issues and fiduciary risks are expected for implementation during conflicts, donors and development partners should not ignore the cost of not providing humanitarian assistance which will likely outweigh the savings from restricting or withdrawing aids from the country. Aid delivery should be made in a way that is not counter-productive and does not shake the trust of the people since there is a widespread anti-military sentiment among the population including towards the health care delivered through military-controlled systems. For the international community, there is no luxury to wait for local health crisis in Myanmar to explode into a regional health crisis. The time to act is now!
The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.