Cigarettes and betel nut – barriers to hospital cleanliness

Daw Cherry Kyaw has been a cleaner at the Yangon General Hospital for nine years. She takes care of the stairwell and entryways of the main building.

She cleans the stairs at 8am and 1pm every day and quietly complains of having to clear the floor of cigarette butts and betel spittle.

It should take her just two hours to finish her work, but with the extra mess it usually takes her twice as long – especially with the hard-to-remove betel stains in the corners of walls or in between stairs.

Patients and guests are on their best behavior around nurses and hospital management, but alone they are less inhibited about littering or spitting on the floors. She has to clean those stairs every day, after collecting the many plastic bags of betel spittle from the wards.

The betel spots can be at the height of a person, on the walls and corners of the stairwell.

“It’s worse when I come back after cleaning the top floor, and notice new spots in places I have already cleaned. Whenever I ask who had dirtied the place, people say that they didn’t notice,” 33-year old Daw Cherry Kyaw told Metro.

Despite being told not to smoke or chew betel nut in the compound, enforcement of rules is not always that strong, said an official from the hospital.

“Although people know the dangers of tobacco and cigarettes, they don’t act like they understand. They reach a level of knowledge that smoking causes diseases, but don’t much care for following the rules and taking action,” said Dr Thein Swe, Vice-President of the People’s Health Foundation.

Dr Khin Theingi Myint, Medical Superintendent of Yangon General Hospital said, “Some people don’t know that smoking and chewing betel quid are banned inside the hospital, but most people who break the rules do so knowingly.”

The challenge of banning cigarette and betel quid in public hospitals

Section 6, Chapter 4, of The Control of Smoking and Consumption of Tobacco Products Law 2006 states that 15 types of public spaces should be designated ‘non-smoking areas’ – including hospitals, medical treatment centres and clinics.

“Hospitals and clinics don’t need to include smoking areas. Smoking is absolutely banned there, and shouldn’t be allowed anywhere on the premises,” said Dr. Thein Swe.

To control smoking and betel chewing, the Ministry of Health and Sports made a notification on March 3 2014 stating that responsible persons are required to display a “No-Smoking Area” sign, visible to all patrons on the premises.

As private hospitals are modern and well-maintained, people are more cautious about littering there. The opposite is true of public hospitals, which often struggle under a stretched workforce and a backlog of patients, said Dr Thein Swe, former Director General of the Ministry of Health and Sports.

Yangon General Hospital has 27 departments, and 1700-1800 intensive care unit patients. Each day the hospital receives around 800-1000 new out-patients – it’s the caretakers, visitors and drivers who accompany these patients who create most of the mess.

When senior doctors go on their morning round checks, the hospital visitors leave the hospital and hang around Bogyoke Road to smoke and chew betel nut.

Cleaners also said that there were those who continued smoking and chewing in the corridors and entranceways. When reprimanded by staff, they would just sneak off to the toilets or outside again.

When they do put out their cigarettes they put them out against the door jamb or iron railings, said a senior nurse on duty.

And some people even smoke besides oxygen tanks, said the hospital administration staff.

A new six-storied building of the Thingangyun Sanpya Hospital was opened on March 16 this year, but betel spit already stains some of the walls and windows, said an official at the hospital.

Although posters warn visitors not to smoke or chew betel nut, only few actually follow the rules.

“It’s important to explain the consequences to people, and for people to follow the rules,” said Dr Daw Than Hla, medical superintendant for Thingangyun Hospital, where 800 in-patients and about 650 out-patients seek medical treatment daily.

Insein General Hospital has about 600 in-patients and 750 out-patients, and also deals with unruly visitors – particularly so with betel nut. A volunteer taskforce was even formed to help clean the hospital of betel spit, an official from the hospital said.

Sale of cigarettes and betel quid outside the hospital

Betel nut and cigarette stalls are commonly found on the busy streets outside of the major public hospitals, catering to the many patients and visitors overflowing onto the street.

Cigarettes and betel quid cannot be sold within hospitals, but outside the Yangon General Hospital there is an estimated 10-15 vendors throughout the day. This makes it easy for those visiting the hospital to get their fix.

Because these vendors operate on the streets, they are effectively out of reach of the hospital’s jurisdiction. Management at the three major hospitals all agreed that action should be taken, according to the Control of Smoking and Consumption of Tobacco Products Law 2006, by the Yangon City Development Committee and the police.

According to the Chapter (8), section 17 of this law, whoever smoking or holding a lighted cigar or cigarette in any non-smoking area, shall be punished with a fine of between K1,000 and K5,000.

Hospitals try to prevent people from chewing betel and smoking in the hospital, but they do not have the authority to impose fines. For laws to be effective, relevant action needs to be taken by the authorities and police, said Dr Mya Lay Nwe, Deputy Director of the Non-communicable Diseases Control Unit of the Public Health Department and Manager of the National Tobacco Control Program.

“In our country, law enforcement officers, especially the police, seem to be more concerned with other things so they don’t necessarily think it’s their duty,” she said.

Currently discussions are being held between the Ministry of Health and Sports, the General Administration Department under the Ministry of Home Affairs and the Myanmar Police Force relating to law enforcement regarding smoking and the chewing of betel nut, it was learnt.


The Ministry of Health and Sports has a plan to conduct a wider range of education programs across the country to control smoking and consumption of tobacco – implemented at the state, region and local levels.

The ministry will try to regulate all cigar and tobacco vendors by negotiating with the concerned region and state authorities, given that laws are different across the country. The ministry will restrict tobacco sales to certain areas only, and provide education programs about selling tobacco to people under the age of 18.

“Cooperating with organisations and other concerned ministries, our ministry is trying to regulate tobacco vendors by a licensing system, so that we can control retail shops and vendors across the country,” said Daw Mya Lay Nwe.

Yangon General Hospital’s medical superintendent Dr Khin Theingi Myint said, “As authorities, we want the hospital to be a cigarette and tobacco free zone. As Myanmar’s biggest hospital, we want to make it clean for both foreign and local people who visit.”

Having rules, and being able to follow and enforce them, is paramount in that regard.

Source: Myanmar Times

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