YANGON (BLOOMBERG) - Myanmar's runaway virus outbreak is presenting wealthy nations donating Covid-19 vaccines and supplies with a tough choice: Work with the generals that overthrew the civilian government, or let the situation spiral further out of control.

Since the military took over in a coup more than six months ago, virus infections and deaths have soared. The country has officially disclosed a few hundred fatalities each day for the past month, though doctors say the real numbers are exponentially higher. The true scope of the catastrophe is unknown, as many citizens avoid healthcare facilities that have recently been the target of military attacks.

Desperation is growing. International aid groups and even the parallel National Unity Government that is challenging the legitimacy of the junta are pleading with other countries to extend humanitarian aid to help Myanmar get control of the situation - even if it means working with the regime that has become an international pariah.

" 'Shaking hands with the devil' is sometimes part of the mandate to reach the people for whom aid and assistance is intended," said Ms Moe Thuzar, a fellow at Singapore's ISEAS - Yusof Ishak Institute.

The threat of an uncontrolled outbreak goes beyond Myanmar, which is already beset with civil conflict, soaring poverty and food insecurity, as well as a plummeting economy.

India to China

The country is nestled in the heart of Asia, with neighbours including China, Thailand and India, that make up about 40 per cent of the world's population and generate US$20 trillion (S$27.25 trillion) in the global economy. Borders in the region can be porous, even in the age of Covid-19, and allowing the virus to spread there creates the potential for new variants to develop, which could cause further havoc.

Diplomats and doctors have warned that half of the country's population may have been infected within the past several weeks, while the United Nations special rapporteur on human rights in Myanmar, Mr Tom Andrews, said the country is at "grave risk of becoming a Covid-19 super-spreader state".

"If you have more infection that goes in larger amounts and is uncontrolled, there's more virus that could spread everywhere else and probably more potential for new strains to develop," said Dr Peter Collignon, an infectious disease physician and professor at the Australian National University Medical School. "The difference is getting vaccines."

But even as health experts warn about the cross-border consequences of allowing the virus to spread unchecked, donors remain hesitant to take action - like donating vaccines - that could be seen as lending legitimacy to a regime that has killed nearly 1,000 protesters.

Suspending support

Countries that once provided assistance to Myanmar suspended avenues of support following the coup. The United States and some of its allies have led international efforts to sanction the military, while others too have implemented restricted or no-engagement policies.

Within the country, senior military officials said they were receptive to a UN proposal to integrate health workers into their Covid-19 prevention measures, despite ongoing conflicts with medical workers. They have also made statements about the possibility of working with ethnic armed groups on immunisation, though the actual measures remain unclear.

Myanmar received eight million vaccine doses from India and China with just over 3 per cent of its 55 million population fully vaccinated, said Mr Khin Khin Gyi, director of emerging infectious disease at the Ministry of Health. The military government is aiming to vaccinate half of the nation by the end of the year, though supply constraints could make that difficult.

On Monday (Aug 16), the military said that an agreement had been reached with manufacturers to purchase an additional 24 million doses. Under the previous government, Myanmar secured enough supply to vaccinate 20 per cent of its population as part of the World Health Organisation-backed Covax initiative, which was designed to make immunisations available to lower income countries. Myanmar is slated to receive four million doses of Pfizer's vaccine in the third quarter through the organisation.

While the US last week announced US$50 million in aid to be given to humanitarian partners in Myanmar, it has not provided vaccines despite donating millions of doses to other countries in the region. US Ambassador to the UN, Linda Thomas-Greenfield, said the government was working with the body and other international organisations to provide direct assistance to the people inside Myanmar, and didn't elaborate on the lack of vaccine support.

Targeting hospitals

Myanmar's Covid-19 outbreak is playing out differently than others in South-east Asia, where healthcare facilities have been overwhelmed by demand and workers have scrambled to find oxygen and hospital beds. Instead, many Myanmar citizens are avoiding local hospitals as attacks targeting medical staff have grabbed international headlines.

There have been more than 250 acts of violence against or obstruction of healthcare workers and facilities in Myanmar in the past five months, according to a report from Insecurity Insight, a non-profit group that tracks threats against people living and working in dangerous environments.

The incidents include raids on hospitals, destruction of Covid-19 treatment centres, and arrests or injuries of doctors and other medical workers. Those who are part of a civil disobedience movement have been a particular target, the group said.

Even so, hospitals in its biggest city, Yangon, have shown signs of being pushed beyond their limits, while local cemeteries become crowded with bodies.

Cooperation with the junta is only part of the picture as aid agencies struggle to pivot from development aid to humanitarian assistance, said Dr Jason Mills, the acting head of mission for Myanmar at Medecins Sans Frontieres. It has been harder to get visa approvals to bring in staff, while cash shortages among banks have made it difficult to fund ground operations.

That leaves much of the onus for the vaccine roll-out on a military that has little support or trust among the public, has few allies abroad and is fighting a civil conflict on multiple fronts.

"In terms of the ability of the de facto authorities to scale up the vaccination response, it's going to be a challenge," Dr Mills said. "It's really hard to achieve that in this kind of politicised and political environment right now."