Medical staff make a three finger salute with red ribbons on their uniforms inside a hospital in Yangon on 3 February, 2021 as calls for a civil disobedience gather pace following a military coup detaining civilian leader Aung San Suu Kyi. (Photo: STR/ AFP)

Medical staff make a three finger salute with red ribbons on their uniforms inside a hospital in Yangon on 3 February, 2021 as calls for a civil disobedience gather pace following a military coup detaining civilian leader Aung San Suu Kyi. (Photo: STR/ AFP)

Long Reads

Crisis upon Crisis: Fighting COVID-19 Becomes a Political Struggle after Myanmar’s Military Coup

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In the aftermath of Myanmar’s coup, a nationwide strike by civil servants and lack of trust in the military regime that staged the February 1 takeover has reversed the country’s hard-won progress in the fight against COVID-19. The potential spread of the virus amongst protestors could accelerate the system-wide collapse of the already fragile health sector.

The last days of March marked one year since the arrival of the COVID-19 pandemic in Myanmar; the country’s first cases were discovered on March 23 and its first death on March 31 of 2020. While neighbouring countries now celebrate the start of their vaccination campaigns, there is little reason for optimism in Myanmar. Senseless, random and premature deaths remain ever-present—not only because of the virus, which continues to spread, but also as a result of Myanmar’s military coup on February 1, 2021. In the three months that followed the military takeover, brutal crackdowns on peaceful protesters have killed over 700 unarmed civilians. In a social media post that went viral last month, Myanmar’s anti-coup netizens took stock of the two compounding crises they faced: “In the first 60 days of COVID-19 in Myanmar, there were just six fatalities, whereas, in the first 60 days of the military coup, 573 people were killed.” The coup thus having caused 95 times the number of deaths compared to Covid-19, the post’s creator, The Insights, concluded that “greed for power is worse than a pandemic.”

COVID-19 has receded into the background of Myanmar’s political landscape since Feb. 1, with the more immediate threat of state-sanctioned violence overshadowing the protracted damage of a global pandemic. But the fact that Myanmar’s military took power at a time when the pandemic continues to spread, largely unabated, has repercussions for the military and anti-coup protesters alike. The already-fragile health sector has seen immediate consequences, and the potential spread of the virus amongst protesters may accelerate its system-wide collapse. Reeling from the economic effects of the pandemic, striking workers face rising food and fuel prices, with little external support. These concrete needs must be addressed, but foreign governments, international institutions, and well-meaning donors should remember that, in the context of Myanmar’s coup, COVID-19 and the broader public health response are not neutral avenues for humanitarian action. COVID-19 prevention has become a strategic pressure point for protesters and the military regime, meaning outside actors must tread carefully, meeting the most urgent needs without undercutting anti-coup activism that seeks to force the regime into changing its course.

MYANMAR’S UNEXPECTED COVID-19 SUCCESS

Experts had expected the pandemic to cripple the country’s long-neglected healthcare system, which, as recently as 2000, was ranked by the World Health Organization as the world’s worst. While healthcare in Myanmar had improved under the National League for Democracy (NLD), at the start of the pandemic, dire statistics underscored the healthcare system’s lack of the basic facilities, infrastructure, and resources needed to control even a minor outbreak of COVID-19. On the last count before the pandemic, Myanmar had just 6.7 doctors per 10,000 people, and just 0.71 intensive care unit beds and 0.46 ventilators per 100,000 people. Into late summer, despite these long odds, Myanmar appeared to have successfully contained the first wave of the virus, reporting just 374 total confirmed cases. However, this changed in mid-August, when community transmission in Sittwe emerged as a turning point in the country’s COVID-19 battle. Ushering in a second wave, by October 2020, the country logged record monthly highs in new cases, at 39,333, and in deaths, at 927.

However, throughout the first and second COVID-19 waves, Myanmar mounted a more robust and comprehensive response than was anticipated, encompassing testing initiatives, the construction of quarantine facilities, food and cash assistance programmes, and strengthened public health policies. Containment efforts were aggressive from the pandemics’ first days. Not only did Myanmar quickly ban flights from Wuhan in January, by Feb. 1, visas-on-arrival were also suspended altogether for travelers from China. The government also quickly set up an inter-ministerial prevention and coordination committee, which was tasked with the government’s cross-sector emergency response. Once testing was adequately scaled up, the Ministry of Health and Sports (MoHS) published regular situation reports and uploaded new caseload data to Facebook each evening. On the whole, international experts were generally impressed with the country’s COVID-19 containment and relief strategies.

Staff shortages at the MoHS resulted in a collapse of COVID-19 testing immediately following the coup. One week after, on Feb. 8, the total number of daily tests amounted to just 1,987, compared to more than 17,000 per day in the weeks before the military takeover.

A local public health physician, who prefers to remain unnamed but has been assisting with the COVID-19 response since last March, shared that: “The programmes put in place were going quite well under the previous government. The officials tried their best to meet all the needs they could, even with their limited resources. That was the general impression, and not only on the health side. The inter-ministerial coordination across sectors was impressive, given that it was the first time the government had approached a problem like this.”

This general agreement on the former government’s success is precisely why Myanmar’s COVID-19 response has emerged as a locus of activism and, equally, a focus of military attention in the aftermath of the coup. With the National League for Democracy (NLD)-led civilian government’s COVID-19 response viewed favourably, the military is keen to show that it, too, can manage the virus’s spread.  

CIVIL DISOBEDIENCE IN THE HEALTHCARE SECTOR

Defying the military regime that took control of the government on Feb. 1, Myanmar’s healthcare workers were among the first to join the fledging Civil Disobedience Movement (CDM). By Feb. 3, more than 70 hospitals and medical departments had joined the nationwide general strike of civil servants included within the CDM movement. Those still working on an emergency basis signaled their rejection of the military regime, wearing ribbons on their scrubs and lab coats as part of a Red Ribbon Campaign. After a month, by March, striking healthcare workers had forced almost a third of public hospitals to close, with more than 50,000 of the Ministry of Health and Sports’ 110,000 employees estimated to be joining the CDM movement.

Myanmar’s COVID-19 response efforts featured prominently in anti-coup activism. Some of the first healthcare workers to join the general strike were posted at the Ayeyarwaddy Quarantine Center. Despite the country’s shortage of COVID-19 treatment and quarantine centres, physicians and nurses at other facilities, nationwide, soon joined. Staff shortages at the MoHS resulted in a collapse of COVID-19 testing immediately following the coup. One week after, on Feb. 8, the total number of daily tests amounted to just 1,987, compared to more than 17,000 per day in the weeks before the military takeover.

The regime has responded to striking medical staff with great force. In his first televised address, senior General Min Aung Hlaing vowed that the new military government would prioritise Myanmar’s COVID-19 response at any cost. On Feb. 22, he declared that striking doctors were in breach of their professional oaths, and, to date, hundreds of striking medical professionals have been arrested. Many have been charged under the Natural Disaster Management Law and section 188 of Myanmar’s Penal Code, which can carry up to two years in prison. Most disturbingly, medical workers have been subjected to outright violence, with a video showing the vicious assault of three volunteer medics, one of whom later died from resulting injuries.

Covid-19 has receded into the background of Myanmar's political landscape since 1 February, with the more immediate threat of state-sanctioned violence overshadowing the protracted damage of a global pandemic. (Screngrab: Nozaki's Art/ Facebook)
Covid-19 has receded into the background of Myanmar’s political landscape since 1 February, with the more immediate threat of state-sanctioned violence overshadowing the protracted damage of a global pandemic. (Screngrab: Nozaki’s Art/ Facebook)

A recent analysis of military propaganda has underscored that state-run newspapers, radio, and television channels have also sought to try striking physicians in the court of public opinion, characterising their actions as dangerous and unprofessional. Striking doctors, conversely, are adamant that they are not only fulfilling their professional responsibilities but abiding by the Hippocratic oath, if outside of military-run institutions. In a letter published in The Lancet, Myanmar’s healthcare professionals address this central predicament: “Our duty as doctors is to prioritize care for our patients—but how can we do this under an unlawful, undemocratic, and oppressive military system?” Their answer is to funnel their energy, skills, and resources into other avenues for care, including private and charity hospitals, local clinics, and mobile ambulances dispatched to protest areas. Doctors have also returned to work when conditions demanded it, as was done amidst a brutal crackdown in North Okkalapa Township in early March.

VACCINATION AS WEAPON?

The country’s COVID-19 vaccination campaign is the latest example of the political uses of the pandemic in post-coup Myanmar. The country received its first vaccine shipment from India, just over a week before Feb. 1. While healthcare workers lined up to receive the vaccine at the end of January, they refused to receive their second doses following the coup.

Recent reports estimate that Myanmar has now purchased 30 million doses of the COVID-19 vaccine, but the rollout continues to face challenges. In late February, the director of the nation’s immunisation campaign, Dr. Htar Htar Lin, joined the nationwide strike and went into hiding, with many refusing vaccinations in solidarity with her. The subject of corruption allegations from the regime, Dr. Htar Htar Lin has since leveled her own criticism in a leaked Signal message. She alleges that the military is using the vaccination drive to recruit civil servants to fill places left by striking staff. This strategy exists, as she describes, “in stark contrast to our [the civilian government’s] well-planned COVID-19 immunization program.” Concluding, she declares, “Vaccination cannot be used as a weapon to keep our country under the boots of the military dictators.”

At a minimum, the most recent reporting on Myanmar’s post-coup COVID-19 vaccination drive has characterised it as poorly organised and subject to extended delays. Those who did choose to receive their vaccines following the coup—over 8,000 individuals—are awaiting their second shots, now more than one month overdue and yet to be rescheduled. While CDM strikers have left public sites too short-staffed to administer additional doses, the ministry also lacks the capacity to organise the private healthcare sector to assist in the programme, although private hospitals have stated they are ready to do so. According to Frontier, it is likely that the country’s current stock will expire before being fully utilised but, even if all doses are administered, the vaccination programme will still be “wildly off course.”

Reports from Yangon indicate that, while the vaccine is now available to the general population, age 65 and over, information about and access to the vaccine have been erratic at best. While some townships were informed of the dates and locations for local vaccine drives through formal notices, other townships’ public health information systems amounted to pre-recorded messages played through speakers atop bicycles, ridden from street to street. While not unheard of, this public health messaging is a far cry from the regular COVID-19 updates posted on the MoHS Facebook page which received tens—if not hundreds—of thousands of shares and comments daily, just a few months before. Those who manage to receive correct information within their townships arrive to find vaccination sites overcrowded with no social-distancing protocols in place. Two eligible Yangon residents who sought vaccines on two different days in April told of lines over one thousand people long, requiring extended waits of approximately 4-6 hours.

Following the coup, many refuse to consider vaccination under a regime that would surely use the total numbers of citizens vaccinated as proof of their effective governance and ability to manage the ongoing health crisis.

Perhaps more worrisome is the decision now facing much of Myanmar’s eligible population. For the sake of individual and community-wide health, as many people as possible should, ideally, be choosing to be vaccinated. However, the military regime’s politicisation of the vaccination drive has muddied what was previously a clear set of factors directing decision-making for individuals and households. Following the coup, many refuse to consider vaccination under a regime that would surely use the total numbers of citizens vaccinated as proof of their effective governance and ability to manage the ongoing health crisis. “I’m not able to get it yet, but wouldn’t even consider it,” explained one 25-year-old young woman, active in the anti-coup protest movement: “If I reject the government outright, and I reject its authority, how can I accept a vaccine?” Others reported rifts amongst their friends and even their families, with vaccination emerging as yet another red line some refuse to cross. For others, though, the decision to accept the regime’s vaccination programme remains relatively straightforward, with the elderly and others in high-risk categories eager to protect themselves against the life-threatening virus. While not all, many doctors, healthcare staff, and other essential workers are opting to get the vaccine given their higher exposure, even as others choose to refuse it in protest. The Yangon-based public health physician quoted above, for example, felt that he should be vaccinated, given both his profession and his intentions to travel in the coming months. But, even with the decision to pursue vaccination made, his worries were far from over: “I was quite concerned about the vaccine from the beginning,” he explained. “I wasn’t sure that the vaccinations would be kept at the required temperature, and I wasn’t confident in the management of the Ministry of Health and Sports since many staff has been on strike since the coup. I asked my contacts to see which centres were most likely to maintain the cold chain. That’s why I chose the centre I did.” But even after vaccination, he waited anxiously: “Even after having had the vaccination, it’s difficult to know whether it will be effective if we are exposed. One good thing happened to me with the vaccine, which is that I had a low-grade fever afterward, which made me feel more confident that I am now likely protected.”

These decisions will become even more grave if case numbers begin to rise—a potential outcome of the protests, given that many participants wear masks sporadically and shouting or tear-gas-induced coughing is an avenue for extensive transmission. “While the number of COVID-19 cases doesn’t seem to have risen dramatically, we can’t know with any confidence,” explained a doctor who, currently on strike, requested anonymity. “The data is non-existent, and so we can only assess based on rumours. Plus, even if we knew hospital admittance figures, it wouldn’t clarify the situation because so few people would consider going to the hospital under these conditions, even if they were sick. It’s much more likely they will die at home.” This doctor, who has been on strike for the past two months, confirmed that he would likely accept being vaccinated once it was safe for him to go out and do so, even if he roundly rejected the military and its authority over the campaign. “If the cases suddenly begin to rise, or if the variants arrive from abroad, I will need to treat COVID-19 patients outside the hospital, and most likely without much protective equipment.” In that case, “vaccination is the most basic decision I can make. It will allow me to save lives in the system-wide cracks that the military’s coup has created.”

Before February 1, Myanmar’s COVID-19 response had underscored the hard-won victories of Myanmar’s healthcare sector, where, as Dr. Htar Htar Lin writes, “we have worked day and night for the past five to ten years, to be able to stand shoulder to shoulder with other countries.” The first 11 months of the COVID-19 pandemic showed this effort’s most immediate payoff in terms of advances in COVID-19 care, an expansive public health response, and transparency in the reporting of case statistics and plans for vaccination programming.

Unfortunately, the coup has upended the national COVID-19 response and, with it, the vaccination effort. While the effective prevention and treatment of COVID-19 is a necessity, this must be weighed against the immediate impact of intervening in a political landscape where healthcare has emerged as a significant pressure point. Foreign governments, international institutions, and donors who choose to assist Myanmar in its COVID-19 response must do so carefully, particularly since propping up government health programmes may weaken anti-coup activists’ positions.



This is an adapted version of ISEAS Perspective 2021/67 published on 11 May 2021. The paper and its footnotes can be accessed at this link.