By Htun Nyunt Oo (LSHTM fellow for Global Health Leadership 2019/20; Director of National AIDS Programme, MoHS, Myanmar)
In this blog series we are giving a voice to practitioners, implementers and policy-makers involved in national COVID-19 responses in low- and middle-income countries. These posts seek to facilitate timely cross- learning by sharing opinions, insights and lessons on the challenges and actions taken by those on the COVID-19 front line.
Myanmar is a lower-middle income country in Southeast Asia, with 70% of its estimated population of 51.5 million people, living in rural and hard-to-reach areas of the country with a diverse ethnicity of 135 ethnic groups, living in 14 states and regions. Myanmar is the source country for an estimated 2.59 million regular migrants while 72% of these migrants (1.86 million) are located in Thailand. Five countries share a border with Myanmar, with China and Thailand making up 70% of these border areas. Northern Myanmar is characterised by a high number of internal labour migrants working in remote mines and seasonal labour migrants that work on banana plantations. In addition, due to the long-term security concern, an estimated 241 000 people are internally displaced and remain in camps across the country.
Investment in health in Myanmar has been steadily growing but remains limited. Recent data from the World Health Organsation (2020) indicates that in 2017, public funding as a percentage of gross domestic product was 4.7%, compared to 1.8% in 2011.The current levels of health investment, along with other development challenges, has resulted in substantial disparities in health outcomes across the various geographical regions and between population groups.
Public Health Control Measures
On 23 March, Myanmar detected its first COVID-19 case. As of 4th May 2020, the country has identified 161 COVID-19 cases and reported 6 deaths. Since the 5th January the Myanmar Government has introduced a series of public health control measures. These early efforts were aimed at reducing economic and social disruption and over-burdening the health care system. Public health measures have included: prevention strategies, such as hygiene and physical distancing measures; restriction of air and land border travel; screening at border entry points and testing of suspected COVID-19 samples at the national reference laboratory; contact tracing of known or suspected COVID-19 cases; progressive lock-down of industries, schools and specific geographical areas; and quarantining, isolation and treatment of suspected or confirmed cases of COVID-19. These measures are not unique to Myanmar and are being used in many countries in response to COVID-19. Some of these measures, as is shown globally, are having inadvertent consequences that are worthy of careful reflection.
On March 26, Thailand announced that it would be closing all its land borders with surrounding countries, including Myanmar. This resulted in a sudden influx of an estimated 76,000 migrant workers that had previously been working in Thailand in key industries such as agriculture, fisheries, construction and manufacturing. This occurred at two Myanmar-Thailand cross-border entry points, Myawaddy and Tachileik townships on the Myanmar side of the border. Myawaddy Township alone, documented at total of 45,498 returning migrants, who were were taken to designated accommodation across all 14 states and regions in the country for 21 days quarantine. In fact, the readiness of quarantine facilities was limited at the beginning of sudden influx of migrants in Myawaddy and other border towns, which has been promptly managed by the local authorities to accommodate 21 days quarantine for all cross-border returnees since 28th March 2020.
Closing the Borders
Over the past 4 weeks Myanmar has also been closing its ‘official’ border crossings with all neighbouring countries. The government however has indicated that it intends to reopen its borders at the end of April 2020, adding to fears of another large influx of returning migrants from Thailand and China. In practice, the stringent closure of borders is not possible due to humanitarian reasons and a small number of migrant workers continue to travel home to Myanmar via ‘irregular’ crossing points, particularly on the border with Thailand. This poses some significant challenges for the Myanmar authorities, migrant families and the local community including: the screening for COVID-19 symptoms on arrival; the provision of facility-quarantine for a period of up to 21 days and basic living provisions at the border and en-route home; preventing the onward transmission of the COVID-19, to populations in transit towns and the destination communities; and the ongoing follow up of returnees.
According to the latest situation report from the Myanmar government, as of the 3rd May 2020, the country has a total of 8 360 quarantine facilities in operation. These currently hold a total of 42,585 people, the majority of whom are returnee migrants. From 31 January until the current time, over 3,227 people are under investigation (i.e. suspected cases being retested). Of the 161 COVID-19 cases detected up to the 4th May 2020, only 26 cases reported travelling to abroad.
Lessons and Challenges
By the time this blog is published, the first wave of returnee migrants from Thailand will end their 21-day quarantine in schools, monasteries and public health facilities located along the border towns and cities across the country. Health workers and townspeople in these areas begin preparing for the second influx of migrants returning to Myanmar around the second week of May 2020. The country continues to learn some important lessons on managing such large numbers of returnee migrants who are especially vulnerable due to job losses and limited access to health care. Key challenges include: the risk of transmission among mass returnees due to crowded border crossings; the sudden heavy demands on frontline health workers, who must fulfill immediate health-related and humanitarian assistance for returnees; growing resistance and fear of returnees among local communities; the sudden burden on border communities who must temporarily accommodate large influxes of returnees in their townships; the socioeconomic impact on migrants and their families, many of whom are being forced into poverty; and the growing need to strengthen and re-shape existing partnerships with implementing bodies and with other government sectors such as housing, labour, social welfare and border affairs.
Some responses by the government and community groups include rapid assessment of the skills and work experience of returnees so they can be quickly placed in new employment under the government’s Employment Exchange Programme; public health awareness activities including the use of loud speakers and pamphlets to reduce stigma and provide information to communities about the prevention of COVID-19; deployment of additional security personnel at the cross-border gates to protect and support the processing and quarantining of migrants; and providing quarantine facilities with essential supplies such as protective equipment, and personal hygiene items for quarantine facilities (sanitation, bedding, towels, mosquito nets, etc.).
Support is also being given by the International Committee of the Red Cross and the Myanmar Red Cross Society are who are distributing food rations, supporting access to health care and ensuring basic water and sanitation systems in conflicted affected areas and IDP camps in Kachin, Rakhine and Shan states. Despite these actions, mental health and psychosocial impacts and physical distancing in crowded camps continues to be a major challenge, and some health workers have also reduced or cut contact with IDPs in an effort to prevent the spread of the virus.
Finally, the capacity of the health system to deliver mainstream health programmes to its migrants workers and displaced people is also being stretched more than ever. Some routine disease control activities have been postponed or scaled back due to disruptions in the supply and transportation of medicines and diagnostics affected by the cancellation of international cargo flights. Limited supplies of personal protective equipment have meant some outreach health workers are reluctant to travel to COVID-19 affected areas, especially to remote rural areas of the country. Seasonal agricultural workers as well as workers in the jade and amber mines (official and undocumented) in northern Myanmar are especially vulnerable to disruptions the delivery of HIV services. In Kachin State, where an estimated 21 800 people who inject drugs live, two out of five people who inject drugs are estimated to be living with HIV. The National AIDS Programme, implementing partners and community networks are attempting to support the continuation of all HIV activities by equipping local communities, shops and prevention workers with extra supplies of needle-syringes and harm reduction tool kits.
Every effort must be taken to minimise the toll of the pandemic on all vulnerable populations, many of whom have already experienced multiple shocks and crises in their lifetime.
Image credit: Cross-border returnees queuing at the Myawaddy Township border checkpoint on 22 March 2020 -Source: IOM/2020/Linn Phyo Maung