the border

Sometimes people ask me why I work on malaria in Thailand.  Most of the malaria in the world, most of the deaths from malaria in the world, occur in Africa.  So if I want to study malaria, why not study in Africa?  An honest answer would have to include the opportunities that happened to fall in place, but there are real substantive reasons to be very interested in malaria in Thailand.

What I actually study is what we sometimes call “border malaria” – a strange pattern where malaria clusters along international borders.  This is the pattern in Thailand, where malaria is almost completely absent in the central plains.

Probably the easiest way to think about these maps is: A. is where the falciparum malaria is, and B. is where it could be.  Maps from the Malaria Atlas Project: http://www.map.ox.ac.uk/

Understanding why this pattern occurs isn’t easy.

If you look at a elevation map of Western and Northwestern Thailand you’ll see that much of that border consists of mountains and hills.  You can't tell from this map, but those same areas are also heavily forested.  This aspect of the landscape has a whole lot to do with the persistence of malaria in this area.  It has a lot to do with ecology (both human and mosquito), politics, demography, economics, and a few other sociocultural factors.

These mountain areas aren’t heavily populated in the sense that Bangkok or Chiang Mai are, but they have been inhabited for a long time.  Along with the Thai who live in this area, most of the inhabitants consist of what are commonly called Hill Tribes.  These are groups of ethnic minorities who live, both literally and metaphorically, on the margins of Thai society.  They have different cultures, different languages, different houses, slightly different ways of making a living, and ultimately different health problems.

They also live in a vastly different ecology than does most of the rest of the country.  The farther away you get from big cities, the more the roads and other forms of infrastructure (including hospitals and clinics) crumble away.  In the wet season everything is soaking wet and the rivers spill over their edges while in the dry season it can be quite hot.  But it’s also a beautiful place, one of my favorite in the world.  I find both the landscape and the people to be awe-inspiring.  

My main study population here is the Karen.  Living along the international border, on the edges of both Thai and Burmese society, things have been quite difficult for the Karen for a long time.  They spent well over half a century at war with the Burmese military and the symptoms of this warfare are far reaching.  The Burmese military would sometimes attack Karen villages, rebel fighters, farmers, school children, monks and all – and villagers would flee across the border into the relative safety of Thailand.  Some set up makeshift refugee camps while others settled into official camps that have existed now for decades.  At times these camps, with huts built almost on top of each other and constructed of bamboo and dried heliconia leaves, would be set ablaze by the Burmese.  (Here is a nice publication about some of this history, from The Border Consortium).

Mae La camp, which is about 30 kilometers south of where I live, has around 50,000 people living in it, including some who are third generation camp inhabitants. Image from: http://en.wikipedia.org/wiki/Mae_La_refugee_camp     

Many things were lost during these years.  Don’t get me wrong, plenty of Karen remained resilient and strong throughout these hard times – they are a lively and outwardly happy people who love to sing and dance, but Karen elders and their knowledge were killed.  People lost limbs to the many land mines that litter this border region.  Some lost their sanity and others lost their hope.  Children lost their chances at education.  All of this for over half a century.  Seriously, imagine a society that hasn’t been able to settle down and focus on families and communities for over 50 years.  Perhaps the greatest loss in this time has been the cohesiveness of such social institutions.

Malaria has been a major cause of both death and sickness for the Karen throughout this time, but these types of conditions make it difficult to focus on a single problem or to even do anything about it.  As malaria researchers have found all over the world, when people have more pressing "for sure" problems (like needing to fill their bellies with food), it is hard for them to worry about invisible parasites in tiny mosquitoes.  Also, preventing malaria means that communities and households need to be working together for this goal.  Community members must work together to ensure people are educated about where the disease comes from and how to prevent it.  Standing water needs to be covered, villages should be well drained, people need to use mosquito nets and they need to seek treatment when they’re sick.  But these are all things that don’t happen when communities are frequently uprooted in the middle of the night only to be forced to move somewhere else, perhaps deeper into mosquito infested forests and hills, to get away from soldiers who wish them harm.  After having to do this several times, people are likely to give up on building permanent communities.  What’s the point when you’ll probably just have to move again one night?  

On the other hand, the Thai have been in a comparatively better position to handle the malaria problem and for most of the country that is exactly what they’ve done.  For most Thais, malaria is a concern of the past.  While I can’t speak for the Thais, I also think many feel as though their neighbors frequently weigh them down.  Thailand is more economically developed than its mainland neighbors (especially Cambodia, Myanmar, and Laos).  Many migrants from these economically poor regions come to Thailand seeking work.  The Burmese are their ancient enemies and while the Karen certainly aren’t the Burmese, they still come from across that border and use the resources (including health care) that are available in Thailand.  The situation is in some ways quite reminiscent of the Southwestern United States, complete with the ill-feelings that some have for the migrants that come across the Mexico border.  The malaria researchers who’ve worked here for a long period of time also have fresh memories of this border area as a dangerous place, where even elephants and water buffalo sometimes step on landmines that were buried years ago and where mortars inadvertently wind up sunk in neighbors front yards.

But money for malaria control and prevention flows into Thailand from lots of different sources (more on that in a future post).  Aid that is specifically geared toward these border populations, frequently channeled through the numerous NGOs in this area, also flows in from many parts of the world.  Yet while the problem almost certainly won’t be fixed in the absence of money, the money must be efficiently directed.  The money doesn’t always make it to the people that need it the most.  Very remote populations that are still on the Burmese side have long been neglected, if for no other reason than because they’re very difficult to reach.  More recently though, there are signs of peace (this is a big point of contention among the Karen!)  More foreigners are allowed into Myanmar/Burma and this means that medical teams have better access to some of these communities.  Even while this is occurring though, there are remote Karen populations on the Thai side that remain ignored.  When I first began working on malaria in Thailand, the story I heard was that most of it came from Burma via migrants.  While that does sometimes happen, it is increasingly obvious to me that small pockets of very high malaria transmission on the Thai side of the border remain.  It’s just that those communities with the most malaria seem to mostly be  non-Thais (for that matter, a lot of people in these areas have no official nationality at all).

And since political reforms have begun in Myanmar, and outside nations have been dropping their sanctions, funding for border related NGOs and other groups has been drying up (see here, here, and here, for example).  I suppose that it was only sexy to donate money when there was an active war going on.  I assure you that the war zone here on the border, and all of its implications, still exists today.  (To be fair, many people want to move their funds into Myanmar.  With that comes the likelihood that some of that money will go to the government.  In my opinion, it also means that many people on the Thai side are abandoned).

I admit that I've only worked on malaria in a few places, but I can't imagine a place in the world where malaria is more obviously linked to social, economic, and political factors.

Now, back to the question that I began this post with: Why do I study malaria here?  Aside from the fact that I just really love this part of the world – there is hope on the horizon and that hope keeps me going.  At one point I was a starry eyed anthropology student who wanted to do something about infectious diseases.  I went to where some of those infectious diseases were, began working with other people in public health (not just Thais), and I found out that not everyone was as passionate as I.  In fact, public health work is a job.  Those malaria funds that flood into this part of Thailand create jobs for people, and some of those people aren’t necessarily concerned about malaria control, prevention, or eradication - some of them just want a job.  And I think this gets at a deeper, more troubling problem that must exist anywhere where there are people who work with health problems.  If you are completely effective, if you actually get rid of a disease, you've actually worked yourself out of a job...

But malaria incidence in Thailand has decreased dramatically since the 1960s and it may even be going down in parts of Burma/Myanmar.  Political changes in Burma/Myanmar mean that there is much less fighting, in this region anyway, than there has been for a very long time.  The resources are here, even if I don’t think they’re always directed in the most efficient way.  I think that many of the young Karen adults are now in a place to learn new skills, take leadership roles, and to gain back much of what they’ve had to do without for so long.  The implication of these things, in particular the latter, I think is that we will see very real changes in the overall health and well-being of the Karen in the very near future.  I’d love to be a part of that.