So Inoue: Experiences Responding to COVID-19 in Myanmar

I am a former surgeon who graduated from the Juku School of Medicine in 1983. I have been working in Myanmar since 2018. I would like to share my experiences encountering the spread of the new coronavirus and the coup d'état in Myanmar.

Sanshikai, the organization I belong to, is a social medical corporation centered around Tomei Atsugi Hospital in Atsugi City, Kanagawa Prefecture. We started an overseas project on the occasion of our 30th anniversary and decided to expand into Myanmar in 2011.

In April 2017, we became the first Japanese medical institution to receive approval from the Myanmar Investment Commission (MIC), and a local subsidiary was established. We struggled with selecting a site for the clinic and obtaining consent from local residents, but the renovation of the local building into a clinic was completed, and I departed for Yangon in July 2018. After facing various other difficulties, it finally took eight years from the decision to expand into Myanmar to open the Yangon Japan Medical Center (YJMC) in February 2019.

The average life expectancy in Myanmar is 67.1 years (2019), which is at the level Japan was around 1960. While average life expectancy is an indicator of the general level of public health rather than the level of medical sciences, it lags behind Japan by about 60 years.

Myanmar's population is 54.4 million (2020), about half of Japan's, but the number of doctors is 35,000 (2017), which is about one-tenth of Japan's 327,000 (2018). The number of nurses is 46,000 (2017), only about one-twenty-sixth of Japan's 1.218 million (2018 workforce).

Since opening, our main operations have been outpatient care and health checkups for Japanese residents. In addition, we conduct health checkups for Myanmar nationals going to Japan, such as technical intern trainees. Our ability to accurately diagnose pulmonary tuberculosis has been highly regarded, and the number of checkups has increased significantly.

In addition to this, I was engaged in awareness activities regarding medical conditions and lifestyle-related diseases in Yangon through lectures requested by the Japan Chamber of Commerce and Industry in Myanmar (JCCM) and other organizations.

The first case of COVID-19 infection in Myanmar was confirmed on March 23, 2020.

Relatively early on, an in-hospital infection occurred at a clinic for foreigners that had examined a foreign patient. The clinic was closed under the guidance of the health center and could not resume operations for over a month. As a result, private hospitals almost stopped examining foreign patients with fevers.

With no other hospitals besides ours examining Japanese patients with fevers, not seeing fever patients was not an option.

If we brought fever patients inside for examination and they turned out to be infected with COVID-19, the clinic would be closed. Therefore, we set up a waiting area and a shielded space for examinations outdoors to serve as a fever clinic.

Masks were becoming difficult to obtain, but we managed to secure them. Procuring protective clothing was also difficult, but we managed to secure it by having it shared with us by others in the same industry.

Since PCR testing was handled exclusively by the National Health Laboratory (NHL), private hospitals, including ours, were unable to diagnose COVID-19.

Because we could not perform PCR tests, our role was to screen patients suspected of having COVID-19 from those with fevers due to other causes, and to refer only those highly suspected of infection to national hospitals.

Furthermore, because there was a lack of appropriate COVID-19-related medical information in Japanese for residents, we continuously provided information about COVID-19 through Facebook. We have posted 85 times so far. This information was also reposted on the Japanese Association's website and widely shared among residents. Later, I also provided weekly serialized COVID-19 information to a web magazine called Myanmar Japon Online.

During this period, several Japanese people were infected with COVID-19, but those with severe cases were hospitalized in national hospitals, and fortunately, there were no deaths.

On February 1, 2021, just as the second wave of COVID-19 infections had passed its peak and was subsiding in December 2020, news broke that a sudden military coup had occurred.

Actually, information had appeared on Facebook a few days earlier saying that a coup was being planned, but as a Japanese person accustomed to peace, I didn't pay it any mind, thinking there was no way a coup would have its information leaked in advance.

For a few days after the coup, it was completely peaceful. After that, initially, simple demonstrations by citizens were held. Then, the military gradually began to crack down on demonstrations, and the number of victims increased.

Next, a boycott of work called the Civil Disobedience Movement (CDM) began.

In Myanmar, a civil movement to pressure the military by abandoning work began with intellectuals in the medical field and later spread to various other sectors. Japanese people might think it is strange for medical workers to boycott because it is the general public who suffers, but in Myanmar, it seems they believe that because the public suffers, dissatisfaction with the military that caused this will increase.

Since healthcare, including the COVID-19 response, was primarily provided by national hospitals, most medical services for the general public came to a halt.

The NHL, which had been conducting COVID-19 testing, was a national institution, so that also stopped completely. The announcements of the number of COVID-19 infections that had been published on the web also ceased.

Banks stopped functioning due to the CDM. The purpose was the same. Not only were individuals troubled because they could not withdraw their savings, but companies also could not withdraw funds and were unable to pay salaries. In this way, actions that troubled the public began as a countermeasure against the military.

Private hospitals were not targets of the CDM and continued to function, but ordinary citizens could not afford the high medical costs. Fortunately, the second wave of the COVID-19 pandemic was subsiding at the time of the coup, but as before, there was a fear that examining foreigners and finding they had COVID-19 would lead to closure, so it was almost impossible for foreigners with fevers to receive medical attention.

Immediately after the coup, it was completely peaceful, but soon citizen demonstrations began. The demonstrations were conducted very peacefully, but as the scale gradually expanded, suppression of the demonstrations began. Once shooting incidents started to occur, the number of victims increased rapidly.

Furthermore, the military's counterattacks against protesters became more extreme, and shooting incidents began to occur even in the city. Some staff members heard gunshots from their homes and were unable to commute because it was dangerous.

Fortunately, YJMC was located in an area considered an upscale residential district in Yangon, so the security in the surrounding area never deteriorated, and I never heard gunshots.

By around April, security in Yangon was stabilizing. However, the number of Japanese residents in Yangon had decreased significantly due to the combination of the previous year's COVID-19 and the coup. Moreover, looking at the country as a whole, various incidents were occurring, and since only major incidents are reported in Japan, instructions were issued from the headquarters in Japan to temporarily close the clinic in Yangon from the perspective of staff safety. It was supposed to be until the situation stabilized and safety was ensured, but since there was no telling when that would be, we unfortunately had to terminate the locally hired Myanmar staff and paid them severance. We have secured the clinic building itself by renewing the lease so that we can resume. Thus, we temporarily closed the clinic at the end of April and returned to Japan.

After returning to Japan, while I was responding to a fever clinic in Atsugi, a third wave of COVID-19 occurred in Myanmar. Myanmar's already fragile medical system fell into an even more catastrophic state due to the CDM, making it difficult even to diagnose whether someone had COVID-19.

As a result, the third wave of COVID-19 in Myanmar became a major outbreak, and for patients who could not go to hospitals or be admitted, the situation became one where long lines formed at oxygen sales points with empty oxygen cylinders in search of oxygen. During this outbreak, several local Japanese residents unfortunately passed away due to COVID-19 infection. When Japanese residents were infected, the Embassy of Japan in Myanmar took the lead in finding local hospitals for admission.

In such circumstances, YJMC continued to provide medical information on Facebook, such as what to do when one thinks they might be infected with COVID-19. Around July, I participated in medical seminars of the Japanese Association and JCCM via the web and gave lectures as a doctor who had been stationed in Myanmar.

After that, the third wave of COVID-19 in Myanmar subsided for the time being, and the medical system had improved to some extent. However, under circumstances where it was unknown when a fourth wave might come, the medical attaché at the Japanese Embassy was to return to Japan, and there truly were no longer any Japanese doctors in Yangon.

Under these conditions, Sanshikai partnered with Medifellow, a company that was already providing cross-border online medical care in countries other than Myanmar, and started online medical consultations in November. We used an existing system, and Sanshikai, which is well-versed in the medical situation in Myanmar, took on the consultations. Thanks to the efforts of the Yangon Japanese Association, for the remainder of 2021, Japanese residents and their families were able to receive medical consultations, including mental care, free of charge as a subsidized project of the Ministry of Foreign Affairs.

We held online briefing sessions at Japanese Association events and JCCM meetings to announce the online medical consultations. The actual content included highly localized questions, such as wanting to know about specialists for intractable diseases in Yangon, whether swollen eyelids might be the effect of a parasitic infection, or wanting to know how to obtain medications locally, and many such inquiries were received.

Although the schedule has not yet been decided, I hope to return to Yangon once the local situation stabilizes and resume the clinic as soon as possible.