Pushing Back TB in Yangon’s Low-Income Communities

As low-income communities across Myanmar struggle amid economic and political crises and widespread armed conflict, the risk of the spread of dangerous infectious diseases like tuberculosis (TB) is growing. Community organizations like Community Partners International (CPI)’s partner, the Hlaingtharya Development Network (HDN), are a vital resource in helping communities prevent and treat this disease.

“I don’t like living here but I do it to survive and for the future of my children.”

After a divorce, Aye, 55, moved with her three children from Myanmar’s Ayeyarwady Delta to Hlaingtharya, an industrial suburb in the commercial capital, Yangon, known for its poverty and deprivation.

Aye works part-time as a housekeeper. Two of her children are in school but her 18-year-old son does manual labor when he can to help the family. The economic impacts of COVID-19 and the February 2021 coup have made survival increasingly difficult for low-income households in Halingtharya and across the country.

“I don’t like living here but I do it to survive and for the future of my children,” reveals Aye. “It’s crowded and suffocating. We live in a 10-foot by 10-foot room. Even though I work and have income, we struggle because prices are rising. Whatever we buy, the price is higher than before.”

During the COVID-19 pandemic in 2021, Aye began feeling weak. “I had no appetite,“ she reveals. “I felt tired and had difficulty breathing. I started coughing and had night sweats.”

Aye’s neighbor advised her to contact HDN and get tested for TB.

TB is a bacterial infection, spread through tiny droplets from the coughs and sneezes of an infected person. It is a serious disease and a very real threat to public health in Myanmar but can be cured with proper treatment. Myanmar is one of 30 countries identified by the World Health Organization (WHO) as having a high burden of TB, HIV-associated TB, and TB drug resistance. The WHO estimates that 194,000 people had TB in Myanmar in 2021, and more than 36,000 people died of the disease. And, according to the National TB Prevalence Survey (2018), Yangon Region has the highest TB burden nationally.

Aye reached out to HDN and met with one of their community workers. “They told me that my symptoms were similar to TB and advised me to go for a chest X-ray and tests,” she explains. “At first, I refused because I didn’t know what I would do if I were diagnosed TB positive. My family relies on my income. But the community worker encouraged me to do the tests and, in the end, I agreed.”

“I received all the support for TB treatment from HDN,” Aye explains. “They helped with the costs and supported me to take the medication from start to finish. I never missed my medication despite the coup and COVID-19. The HDN community worker brought it to me every month even though the health facilities had closed. I’m sure they had difficulties getting the medication, so I’m really grateful to them.”

“They also provided nutrition support such as rice, eggs, and oil,” Aye confirms. “They kept my case confidential but I couldn’t work because of my health. We had to depend on my son. I felt so stressed at that time but the community worker encouraged me whenever I needed help. Now, when I come across someone with TB symptoms, I always advise them to contact HDN.”

“Without our support, I don’t think many would proactively seek treatment because of poverty.”

HDN community worker Win has personal experience of TB. “One of my family members got TB in the past,” he explains. “I know the challenges when someone you love has it.”

Like Aye, Win moved from the Ayeyarwady Region to Hlaingtharya as a migrant worker. He knows well the challenges they face. “I empathize with them and understand their difficulties,” he affirms. “They are struggling for their livelihoods and can’t afford to get sick. They worry about the cost of treatment and don’t have time to seek help while they are working.”

“Migrant households live in tiny rooms without windows,” Win continues. “It’s cramped and crowded. Commodity prices and rents are rising, but their incomes are not. Living standards are getting worse here.”

And Win thinks that TB cases are increasing. “In my opinion, there have been more TB cases in the last three years due to population density and the lack of stable work that pays a living wage,” he reveals. “There is also a lack of health education.”

Community workers like Win have to overcome many barriers to encourage people to seek TB testing and treatment. “People are concerned about discrimination if they get TB,” he explains. “For example, their landlord might throw them out if they hear about it. They also worry about income if they can’t work during treatment. That’s why they refuse tests and won’t reveal their status to others.”

Nevertheless, HDN’s embedded position of trust among Hlaintharya’s migrant worker population helps them to reach people in need of their services. “We connect with patients who have TB symptoms and we help with chest X-rays and sputum tests,” Win continues. “If we identify a suspected case, we bring them to a clinic for further tests. If they test positive, the doctor refers them to the hospital.”

“There are often long queues at the hospital to collect medication,” Win explains. “Our clients can’t afford to lose income while they wait, so we collect the medication for them. During COVID-19, we also collected and delivered medication to patients’ homes. We encourage them to take their medication every day and provide health education including ways to prevent TB transmission to others. So far, none of my clients have missed their medications.”

Fear of discrimination also makes home visits for treatment and side-effect monitoring challenging. “Most patients don’t allow us to visit their homes,” confirms Win. “So, we adapted to follow up by phone.”

And Win underlines the importance of continuing HDN’s work. “TB is not in decline here. Living and working conditions are the main reason. If a factory worker gets it, it’s very easy to transmit it to others in these cramped places. Without our support, I don’t think many would proactively seek treatment because of poverty. That’s how we are effective.”

“They call me frequently to remind me to take the medication and ask about my health. It’s all free of charge.”

Community Partners International has supported HDN’s TB diagnosis and treatment activities in Hlaingtharya since 2017. HDN’s services reach a population of around 74,000 people in the township. In 2023 so far, the project has enrolled 93 people in TB treatment.

Zarni, 31, lives in Hlaingtharya and works part-time construction jobs. He’s now in the third month of TB treatment with support from HDN.

“I live with my mother and younger sister,” he explains. “My father died many years back. I’ve worked in construction since I was eighteen. Sometimes painting, sometimes carpentry. My sister works in a garment factory. It’s hard to find stable work. We struggle to earn enough to pay rent and buy food.”

A few months ago, he experienced a persistent cough, began to lose weight, and felt sick every evening. A neighbor referred him to HDN. “I met with the volunteer,” he explains, “and they helped me to get an X-ray and sputum tests. I don’t need to go to the hospital to collect the TB medication because they do it for me. They call me frequently to remind me to take the medication and ask about my health. It’s all free of charge.”

Zarni had little understanding of TB before he was infected. “I’d heard the term ‘TB’,” he reveals, “but I didn’t know about symptoms or how it could be transmitted.” Now, using the information received from HDN, he is doing his best to prevent passing the disease on to others. “I just keep to myself now,” he confirms. “No one in my family has shown any symptoms. If they do, I’ll contact HDN.”

Luckily, he has received support from his community. “No one has discriminated against me. My friends and family members are encouraging me that I will recover soon if I take drugs regularly. It is helpful for me.”

The family’s financial situation has become more precarious as Zarni has had to give up work during his recovery. “I don’t have any income, and we rely on my sister at the moment. It’s not enough for all three of us, but there’s nothing else we can do. Commodity prices are rising too. Sometimes, we have to borrow money to buy rice and other essentials and then pay it off with interest when my sister gets her salary. It makes me feel guilty.”