Paying for Oxygen in a Respiratory Pandemic

With reporting and photography from Aung Naing Soe.

Eaint didn’t dare question the hospital worker when she asked for money. Her father, struggling to breathe because of COVID-19, depended on the oxygen the worker provided. Every time the oxygen cylinder connected to a breathing mask was replaced she paid around 5000 Myanmar kyat, or US$ 3.82, the equivalent of a day’s labour.

Eaint feared the isolation ward staff at the East Yangon General Hospital, also called Gandhi Hospital, would prioritise other patients if she didn’t pay. The cylinder needed to be replaced three to four times a day. In total, she forked over between MMK 70,000 and MMK 80,000, about two weeks labour at minimum wage, for oxygen and wheelchair services.

In the end, the bribes didn’t matter, as her father passed away anyway.

“My dad had passed away because the nurses were taking 20 minutes between the two oxygen bottles. He didn’t survive the gap,” Eaint stated in an email to Global Ground Media. He was never put on a ventilator. (Eaint’s name has been changed at her request for fear of retaliation.) A doctor at East Yangon General Hospital declined to comment about the bribes.

Publicly, health care officials maintain that Yangon hospitals are able to handle the daily influx of COVID-19 patients, with sufficient manpower, supplies, protective gear and equipment available for all.

Reporting by Global Ground Media, however, uncovered a different reality. People say they are asked to pay so-called “pocket money” by staff when providing basic care. They detail overcrowded hospitals without proper social distancing measures, where patients suspected of infection have to spend the night, sometimes on the floor, in close quarters with others while they wait to be tested for COVID-19. And finally, according to several accounts, people gasping for breath die for lack of oxygen, never having been put on a ventilator.

Eaint’s story is echoed in similar stories shared on condition of anonymity. Global Ground received two separate accounts of bribes and patients passing away without being put on a ventilator. We also collected eight stories of overrun facilities lacking proper infection containment measures. While the numbers appear minor, the willingness to speak up is significant: Corruption remains a sensitive topic in Myanmar with few people, including journalists, willing to risk the potential repercussions of exposing it.

Human Rights Watch (HRW) noted that self-censorship is a “survival strategy” for media caused by the arrests of dozens of reporters since the National League for Democracy came into power in March 2016. “Myanmar reporters working for smaller international media outlets or national publications are now thinking twice when taking on sensitive topics such as […] government corruption,” HRW states.

Some of these stories reported here are interviews while others are social media posts. Global Ground Media gathered posts from a public Facebook group with over 750,000 members between 22 March and 13 October. We contacted the posters and verified their Facebook accounts.

Pocket money

On 9 October, May shared her story in a public Facebook group. “[A] nurse or a nurse’s aide [at Yangon General Hospital] asked for pocket money from my younger sister,” she stated in a public Facebook group.

The sister was accompanying her father who had contracted COVID-19. She offered MMK 10,000 since that was all she had. “The nurse said it was not enough, but she took it and told her to keep it a secret.” May and her mother were in quarantine and were not able to send money to the other family members at Yangon General Hospital.

May shared her story to warn others, but the moderators had to turn off the comments to her post as people were criticising her for sharing the corruption story. One comment reads, “You should feel sorry for the medical staff. They are risking their lives in these times. It’s wrong to complain just because you had a small inconvenience.”

Professor Dr. Maw Maw Oo, Head of the Emergency Department of Yangon General Hospital, said the hospital acts swiftly to root out bribery and shakedowns of patients and their families. “Whenever we find out about it, we take action. It seems like it has been their side business. It was even worse before, but it has long been forbidden. I don’t know how it’s happening during the COVID [pandemic].”

Dr. Maw Maw Oo said asking for money is against hospital policy, but it could happen. “It’s possible… But we have told them many times not to do it. There are rules against it, too.”

According to the latest data from the Global Corruption Barometer, 32 percent respondents in Myanmar said they paid a bribe in the previous year. On a scale of 0 to 100, with 100 being the highest score, Myanmar only collected 29 points on the Corruption Perceptions Index by Transparency International, and ranked in the bottom third of countries for corruption.

Ventilators

Despite the payments, May’s father also passed away. “When my father had difficulty breathing, my sister requested assistance from the nurses so frequently that they stopped paying attention to her. I called the doctor and begged him to help and he said that he gave my father an injection,” May said. She later posted, “My father passed away this morning. He had difficulty breathing and couldn’t make it.”

Myanmar only has 900 ICU beds for a population of 53 million.

The Myanmar Health Ministry has not disclosed publicly how many ventilators are in the country. The World Bank counted 249 ventilators in Myanmar in March. Since then China donated 35 ventilators and telecommunication giant Ooredoo donated an unspecified number of ventilators.

The Myanmar government also purchased up to 119 ventilators from eight different companies earlier this year, according to procurement reports on the website of the Ministry of Planning, Finance and Industry.

Assuming the government bought 119 ventilators and Ooredoo donated up to 10 ventilators, the estimated number of ventilators adds up to between 404 and 413. This would mean that less than half of the ICU beds have a ventilator, which is woefully inadequate for a population of Myanmar’s size.

(For comparison, the United States, with a population of 320 million, or six times the population of Myanmar, has over 200,000 ventilators on hand.)

Dr Khin Khin Gyi, director of the Central Contagious Disease Prevention and Eradication Sub-Department at the Ministry of Health and Sports (MOHS), told Frontier in March that six out of 100 COVID-19 patients require ventilators. On 4 November, there were 14,832 active infections (confirmed patients not yet recovered or passed away). This would add up to 890 patients requiring ventilators on that day.

And according to Dr. Maw Maw Oo, patients are getting sicker. “The main problem is that the patients are getting worse. Their symptoms are getting more severe. So we have to be more careful when we give them treatment.” But the hospitals are already struggling to handle the number of cases and facilities are overrun.

Breaking Point

Aung lost his sense of smell and went to Yangon General Hospital on 21 September. He had to sleep on the floor of the Emergency Room while waiting for a COVID-19 test, and share one toilet with 100 other suspected COVID-19 cases.

Global Ground Media reviewed a video made at the admissions area of the emergency department at Yangon General Hospital, showing dozens of patients and family members with no measures for social distancing. This video was publicly shared on Facebook, in the channel Covid News Update. The owner of the video confirmed to Global Ground Media the video was shot at 8 October at Yangon General Hospital.

The admissions area appears overcrowded: patients line the hallways, sitting in chairs instead of on beds, and blocking doors and staircases.

Since March, the Myanmar government struggled with providing enough beds to confirmed and suspected cases of COVID-19. On 7 October, Professor Dr. Zaw Wai Soe, vice chairman of Yangon’s Committee on the Prevention, Control and Treatment of COVID-19, said the overcrowding was a thing of the past.

He told Irrawaddy, a news website,  that “the region’s health-care facilities now have sufficient capacity to handle the daily influx of COVID-19 patients”. He stated there were 10,000 available hospital beds, of which 900 are in the ICU.

Within 6 weeks of his remarks, COVID-19 cases increased more than fivefold in Myanmar, to almost 90,000 on 29 November.

Professor Dr. Maw Maw Oo, Head of the Emergency Department of Yangon General Hospital, confirmed the capacity problem on 21 October. “We have problems because there are two or three times more patients than we can manage. The hospitals are filled beyond capacity due to a high infection rate.”

According to Dr. Maw Maw Oo, new buildings and tents are currently being constructed to handle the influx of patients at Yangon General Hospital. But the pandemic has also depleted the hospital’s staff. “There have been infections among our staff,” he added, “therefore [the] reduced number of staff has also been a challenge for us.”

Containment centres turned super-spreader?

In addition to a lack of beds, ventilators, staff and space, Global Ground Media received accounts of safety measures not being implemented properly. Overrun facilities risk turning into super spreader locations of COVID-19.

In the previously mentioned video, several patients lack face masks and there is no social distancing between patients. This is confirmed through other accounts.

“There was no separation between people with mild and severe symptoms”, Aung told Global Ground Media. After spending the night among 100 suspected cases, he was finally administered the COVID-19 test the next morning and moved to a separate room together with 11 others experiencing mild symptoms.

“When the result came back on 23 September [two days after he went to Yangon General Hospital], only four out of the 12 mild cases were negative,” added Aung.

Eaint’s father suffered severe symptoms, and was moved to the isolation ward at East Yangon General Hospital. She stayed at his bedside to care for him. (In Myanmar, it is common for family members to accompany loved ones at the hospital.)

“I and my father stayed in a room [with] three other patients in the same room. There were no toilets and the nurses told us to use plastic bags for our faeces. We were not allowed to leave the room. They didn’t even disinfect the bed for a new patient,” Eaint said via email.

Dr. Maw Maw Oo responded to the allegations. “[L]et’s say, we have 100 patients and 99 of them died, don’t blame hospitals because [the people] need to [make sure they won’t get] infected. Hospitals are receiving more patients than they can [handle] because of the high infection rate.”

To alleviate the pressure on the limited number of hospitals admitting COVID-19 patients, MOHS announced plans to enlist private hospitals to care for COVID-19 cases in early September, but it hasn’t done so yet. MOHS did not respond to repeated requests for comment.

Since October, “fever clinics” started testing for COVID-19 using rapid antigen tests, alleviating some of the testing pressure on hospitals. Mild cases can bypass the hospitals altogether and are sent to so-called “no-smell clinics”. No-smell clinics are aimed at housing mild cases, and can hold up to 500 people.

To support COVID-19 hospitals further, several quarantine facilities started taking more serious cases requiring oxygen supplementation. Others are in the process of scaling up. But the quarantine facilities are reportedly also under strain to handle the influx of patients. Many quarantine and medical facilities depend predominantly on volunteer medical staff and donations from the public.

A doctor at a fever clinic in Mingalar Taung Nyunt Township in Yangon, who spoke on condition of anonymity, said the clinic was struggling without any outside help. He shared the difficulties he and his team face “Until now, we have not received any financial support from the government, not even one kyat, the doctor said. We have been working in the fever clinic since April. It has been 7 months now.”

The volunteer staff does not receive a salary and misses out on their regular jobs. The community stepped in to donate daily lunches,  the doctor added.

Policy problem?

Myanmar has adopted a “containment strategy” where all confirmed cases have to be quarantined at facilities for 11 days, even if experiencing only mild symptoms or no symptoms at all. If medical and quarantine facilities are struggling to handle the caseload, questions arise if this strategy will work in the long-run.

The current containment policy could backfire and discourage people from going to medical facilities on time.

After his experience, Aung took to social media to warn others. “If in doubt, I would like to advise those who want to know whether or not to come [to the hospital]. If your house is big, has space to isolate yourself, and is well ventilated, it is better to opt for quarantine at home,” he posted on Facebook on 25 September.

Dr. Maw Maw Oo says staying home comes with risks. “[I]f people get infected, they should seek treatment as early as possible. If they only come to the hospital when they get too exhausted, have difficulty breathing and their oxygen situation is 60 or 70 [percent], no one can survive.. no matter how great the healthcare system is,” he told Global Ground Media.

Myanmar currently has the third largest outbreak in Southeast Asia after Indonesia and the Philippines. Cases continue to rise and threaten to overrun the limited health care provisions.

Myanmar is the poorest country in Southeast Asia. In 2017, 4.7 percent of GDP was spent on health care which at US$ 58 per capita, compared to US$ 247 in Thailand.

The limited budget and the scale of the pandemic explains to some extent that facilities are overrun, but the public has expected some improvement, with hundreds of millions of dollars in international funding since the first cases in March. The IMF donated US$ 356.5 million and Japan donated 45 billion Yen (US$ 432 million).

A spokesperson for UNOPS Myanmar stated that “[s]ince the first case was detected, UNOPS Myanmar has pivoted US$ 43.6 million to support the country’s health response and US$ 31.2 million in mitigating the socio-economic impact the pandemic has on Myanmar”.

The UNOPS spokesperson referred to MOHS for questions about the management of medical and quarantine facilities.

On 8 October, “Yangon health officials said they were considering switching to a community containment strategy, in which COVID-19 patients with mild symptoms would be told to stay at home”, Irrawaddy reported. On 4 November, the spokesperson for MOHS said the government is considering changing the policy “in the coming months”.

To date, that policy hasn’t changed “even as the number of cases continue[s] to rise and inundate[s] hospitals”.

Dr. Maw Maw Oo shares his take on home isolations of mild cases of COVID-19. “If we don’t do containment [at medical facilities], the virus will spread further and quicker.”

The doctor at the fever clinic said that patients are advised to stay home because the maximum capacity is reached. “People call us every day from everywhere. They all say that they have symptoms. Their symptoms are not so severe, so we can’t tell them to go to the hospitals. We are unable to run the tests here either. We just tell them to stay in home quarantine. In actuality, there are a lot of infections in the wards.”

Even if all efforts are stepped up significantly, the question remains if Yangon hospitals can add enough beds to meet the rising number of cases. Within 6 weeks, the caseload increased more than fivefold and the end is not in sight, as economic pressure increases for people to return to work. Before the pandemic, 25 percent of the population was living below the poverty line and a third was in danger of falling into poverty, according to the latest data from 2017 by the World Bank. The International Food Policy Research Institute found that poverty had already risen 27 percent until June 2020 due to the pandemic. Until late August, the number of COVID-19 cases was relatively low, so poverty has undoubtedly increased even more in recent months.

Yangon Region has been under a stay-at-home order since 21 September and people could not go out to work. Reuters reports that the situation in some impoverished areas is so dire that residents have taken to eating rats and snakes.

The World Health Organization advises countries to only consider lifting restrictions if the testing positivity rate has been 5 percent for two weeks, otherwise countries risk another wave of infections. But the day labourers of Yangon who don’t receive a fixed monthly salary might not be able to stay home until then.

The 8 November general election led to an increase in cases, as polling stations in Yangon struggled with maintaining social distancing measures. Maw Maw Oo told the Myanmar Times that Yangon General Hospital was treating 90 to 100 patients per day before the election, which rose to 200 per day on 26 November.

Already Yangon hospitals are struggling to care for all suspected and confirmed cases.