Improving access to healthcare can usually make malaria go away

Drug resistant malaria has emerged in Southeast Asia several times in history and subsequently spread globally. When there are no other antimalarials to use this has led to public health and humanitarian disasters, especially in high transmission settings (parts of sub-Saharan Africa).

Currently there is a single effective antimalarial left: Artemisinin. But malaria parasites in Southeast Asia are already developing resistance to this antimalarial, leading many in the malaria research community and in public health to worry that we will soon be left with untreatable malaria.

One proposed solution to this problem has been to attempt to eliminate the parasite from regions where drug resistance consistently emerges. The proposed strategy uses a combination of increasing access to health care (so that ill people can be quickly diagnosed and treated, therefore reducing transmission) and targeting asymptomatic reservoirs by asking everyone who lives in a community where there is a large reservoir to take antimalarials, regardless of whether or not they feel ill (mass drug administration).

In Southeast Asia malaria largely persists in areas that are difficult to access and remote. The parasite thrives in conflict zones and in the fringes of society. These are the areas that frequently don’t have strong healthcare or surveillance systems and some have even argued that control or elimination would be impossible in such areas because of these difficulties.

Today on World Malaria Day my colleagues and I published the results after 3 years of an elimination campaign in Karen State of Myanmar.  The job is not complete. But this work has shown that it is feasible to set up a health care system, even in remote and difficult-to-access areas, and that most villages can achieve elimination through beefing up of the health care system alone. In places where there are high proportions of people with asymptomatic malaria, access to health care alone doesn’t suffice and malaria persists for a longer period of time. With high participation in mass drug administration, which requires a large amount of community engagement, these communities are able to quickly eliminate the parasites as well. We are hopeful that similar programs will be expanded throughout Southeast Asia, regardless of the geographic and political characteristics of the regions, so that elimination can be achieved and sustained.

Malaria (P. falciparum) incidence in the target area over three years. The project expanded over the three years, and overall incidence has decreased.

Link to the main paper:
Effect of generalised access to early diagnosis and treatment and targeted mass drug administration on Plasmodium falciparum malaria in Eastern Myanmar: an observational study of a regional elimination programme

Link to a detailed description of the setup of the project:

Scale up of a Plasmodium falciparum elimination program and surveillance system in Kayin State, Myanmar

Lunch with the Captain

These days I’m having trouble finding time to write, especially to blog.

My colleagues and I are busy building a team and a large network of collaborators for a series of related malaria elimination projects.  Our initial goal in this project is to wipe malaria out in very specific populations.  If this works, and from our initial work at a smaller scale it appears as though it can, it will be vastly scaled up – reaching throughout Southeast Asia.

The impetus for this work is the so-called evolutionary arms race.  This part of the world has a very long history of popping out drug and multi-drug resistant strains of falciparum malaria (C Wongsrichanalai et al., 2001; Chansuda Wongsrichanalai, Pickard, Wernsdorfer, & Meshnick, 2002).  We (malaria workers) roll out a new line of defense (antimalarials) against our chosen adversary, and our adversary quickly develops a defense strategy against us.  These strains can subsequently move from this part of the world to others, parts of sub-Saharan Africa for example, where the malaria burden is much heavier and the results would be much more devastating (Payne, 1987).

Occasionally there are deaths from malaria infections here along the Thailand-Myanmar border (though usually the major toll the illness takes here is in time spent ill and therefore unable to work.)  Not that long ago, a 15 year old boy died from malaria.  He was not far from health care clinics that would have treated him.  The story I hear is that he was without close family members, he lived alone and worked in the agricultural fields, and that he essentially lay in those fields dying from the disease through an apparent gap in his and his community’s social network.  Everyone was devastated.  If complete drug resistance were to reach Africa, this story would be magnified in both space and time.  Even where the social networks were strong, the health clinics wouldn’t be able to adequately treat people with malaria.  The geographic reach would be huge and the numbers of death would likely dramatically increase.  This can’t happen.

Today our last, best tool against malaria is artemisinin and its derivatives.  But already throughout Southeast Asia researchers and health care workers are seeing parasites survive much longer in the human hosts after being treated with artemisinin (Ashley et al., 2014).  How much longer will it work at all?  And should we really wait to find out?  It often feels as though everyone around here has been doing the same “malaria control” game for a very long period of time, regardless of the fact that the outcome is always the same.  Our drugs stop working and we have to start over again.  Sometimes this problem is exacerbated by a lack of information and/or the dissemination of scientific knowledge.  Many of my Thai colleagues who actually work in direct malaria care in this area just learned last year (2013) that resistance to artemisinins might be occurring or even growing and spreading in their region.  A major scientific paper on this (that I’m aware of) came out 5 years ago (Dondorp, Nosten, & Yi, 2009), with rumors of it almost 10 years ago (Noedl et al., 2008)!  Shouldn’t the people who live in the war zone know that a war is happening!?  What a failure of science – and of our strategy over the long term.  It is time for a change.

So what we’re working on is a tool that we’re calling “targeted chemo-elimination.”  Essentially this is a form of mass drug administration.  That is, everyone in a targeted community would take drugs (antimalarials) regardless of whether or not they felt sick (some recent thoughts on this here, here, and here).  It is much more complicated than this though, in that it isn’t a single strong dose of the antimalarials, we’ll be using a cocktail of drugs so that we can hope to avoid further driving resistance, and since the administration will occur over time, over several stages, we’ll be able to vary this cocktail if necessary.

Logistically this is extremely difficult to pull off.  It is hard enough to get people in easy to reach populations in places like the U.S. to take medicine when they feel sick, let alone to take a vaccine that would prevent them from being sick.  How do we go about convincing people in extremely remote populations, frequently in the middle of old or continuing conflict zones, to take medicine, over a long period of time, regardless of whether or not they are currently feeling sick?  It isn’t easy.

But it can be done and the way to do it is through community engagement – drawing on notions and principles well-known in anthropology and other social sciences.  It can happen when there is understanding, trust, and social cohesion.  Sometimes these things are lacking in our target communities between members of the community, and/or between us and members of the community, and it is therefore important to build them up.  Sometimes we need to plant a seed, water it, foster it, and help it to grow.

This is exhausting work, physically, psychologically, and emotionally.

A little while back I made a trip to one of the communities in our target area, to visit local people and share some of what our project is about.  I wound up eating lunch at a table full of “freedom fighters”, some dressed in fatigues and drinking whisky out of small coffee cups.  A captain who was sitting at the table gave me a history lesson, translated to English through one of my colleagues who speaks both my tongue and the local language.  I heard stories about being betrayed by colonialists who promised these people their own land but never followed through and of people who were willing to die for that land, many of whom did in fact pay that price.

Among the things he said to me was that he admired two major things about Americans.  One is that their time is their money (time is extremely valuable).  And the other is that they realize they have a burden, to help others, that is bigger than a mountain (we were sitting at the base of a relatively large one).

I don’t know if this generalization is true of all Americans and I don’t care to go into that.  But I do know that time is of the essence and that I feel a burden.  There is a lot of work to do, and not so much time in which to do it.

*** As always, my opinions are my own.  This post and my opinions do not necessarily reflect those of Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, or the Wellcome Trust. 

Ashley, E. a., Dhorda, M., Fairhurst, R. M., Amaratunga, C., Lim, P., Suon, S., … White, N. J. (2014). Spread of Artemisinin Resistance in Plasmodium falciparum Malaria. New England Journal of Medicine, 371(5), 411–423. doi:10.1056/NEJMoa1314981

Dondorp, A., Nosten, F., & Yi, P. (2009). Artemisinin resistance in Plasmodium falciparum malaria. The New England Journal of MedicineEngland Journal of …, 455–467. Retrieved from http://www.nejm.org/doi/full/10.1056/nejmoa0808859

Noedl, H., Se, Y., Schaecher, K., Smith, B., Socheat, D., & Fukuda, M. (2008). Evidence of artemisinin-resistant malaria in western Cambodia. N Engl J Med, 359(24), 2619–2620.

Payne, D. (1987). Spread of chloroquine resistance in Plasmodium falciparum. Parasitology Today (Personal Ed.), 3(8), 241–6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15463062

Wongsrichanalai, C., Pickard, A. L., Wernsdorfer, W. H., & Meshnick, S. R. (2002). Epidemiology of drug-resistant malaria. Lancet Infectious Diseases, 2, 209–218.

Wongsrichanalai, C., Sirichaisinthop, J., Karwacki, J. J., Congpuong, K., Miller, R. S., Pang, L., & Thimasarn, K. (2001). Drug resistant malaria on the Thai-Myanmar and Thai-Cambodian borders. Southeast Asian J Trop Med Public Health, 32(1), 41–49.

Kah Tah Blay Learning Center Graduation

by Daniel and Amber Parker

In a break from what we normally blog about here at MT, today my wife and I thought we’d share some of what we’ve been up to lately.

We’ve been living at a field site on the Thai-Myanmar border since July 2013 and today we’d like to gloat a little about a project that we’ve been involved with over the last year – Kah Tha Blay Learning Center (KTBLC). KTBLC is a small school along the Thai-Myanmar border about 2 hours north of Mae Sot.

The school rose from a need to educate young Karen adults because education opportunities, especially on the Burma side of the border, were almost completely absent (some boys could attend limited schooling provided by monks at Buddhist temples).  Until very recently, the Karen were involved in the longest continuous civil war in recorded history – lasting over half a century.  During this time most able-bodied men became soldiers, meaning that they had little role in community developments etc.  Villages that existed in conflict zones were forced to frequently move, with Burmese military troops setting them on fire, often as villagers slept.    

A lot of knowledge was lost during this time.  Traditional approaches to farming were among them.  For those who wound up in refugee camps on the Thai side of the border, very little farming continued at all – there is extremely limited land available and rice is provided for each household.  For these people, some safety was provided by the rice and relative protection of the Thai side, but traditional subsistence practices and leadership roles were lost.  A major goal of the school is to address these issues. Kah Tha Blay means Freedom Country.

The school headmaster and principal are Karen, as are several of the teachers.  Funding comes through an NGO, Project Umbrella Burma, which is based out of Canada – however the ultimate goal is to have the school completely self run (with Karen people raising the necessary funds) in the near future.

The school headmaster (Kshakalu) at Karen New Years Celebration

Singing around the campfire

The school has physically moved around a bit over the years, beginning within a refugee camp as a school/hostel and then expanding to include a junior college for students who passed the 10th grade (there are very few opportunities for students to continue education after the 10th grade in the refugee camp(s)). The junior college was originally built in Burma, but due to the continuing violence and safety concerns, had to eventually be moved to the Thai side of the border where it is located today. Student ages range from about 18 to 25.  Because the school is on the Thai side of the border, they learn Thai, raise a Thai flag in the morning, and say the Thai pledge of allegiance (followed by a Karen-styled version of “We shall overcome” – directed (I think) at the Burmese conflict).  

Perhaps one of the most interesting, probably provocative, aspects of this school is that one of its goals is to address the very real “brain drain” problem.  That is, the most educated Karen usually wind up moving abroad and rarely or never return to their home communities.  The students who are accepted into KTBLC have promised to return to their communities when they are done learning, even if they go on for further training after KTBLC.  So far, it looks like many actually do wind up going back to their homes.  On an individual basis, we see students who we think would do great in a university setting, and we very much want to help them pursue that sort of path.  These are probably the same ones who will go on to be strong leaders that the Karen need in Karen state.

 

The school is set in a very small village, in a terraced rice paddy field that is surrounded by mountains.  A typical day for them begins early in the morning, when they begin chores around the school or participate in extracurricular activities like sports and traditional “Don” dancing.  They grow much of their own food (which is part of their education process), cook their own food, and are in charge of the upkeep of the school buildings and grounds.  They take regular courses each school year including subjects like English, Community Health, Thai and Math, supplemented with various other topics that volunteers provide throughout the school year - Leadership, Photography, Journalism, etc. The students prepare lunch during the middle of the day and dinner after classes end in the evenings followed by more chores and study hour before lights out. Some are able to visit family members in the refugee camps on the weekends while the others (without family in the camps) remain on campus. 

typical landscape in the area

Over the last half year or so we have volunteered out at the school, teaching public health, computer skills, and creative writing.  Since English isn’t their first language, it can be quite a challenge.  Sometimes they don’t completely understand the knowledge that we try to pass on, but it is probably the case that they at least benefit from hearing English being spoken by a native speaker or from hearing about and seeing pictures from parts of the world (e.g. the U.S.) about which they know very little.  

We’ve grown quite attached to these students.  It’s hard not to.  These are students who REALLY want to be in school, who are thirsty for whatever knowledge someone will pass on to them, even if it’s not a subject that they’re particularly interested in.  

They work hard, but there is also a captivating form of light-heartedness in everything that they do.  Moments are never dull.  Quiet periods during the day, for example while working independently, are filled with students singing; sometimes a single student, other times the whole class. They are very community oriented and enjoy working and learning together. 

several of our students watching Karen Revolution Day ceremonies

Revolution Day 2014

students performing a skit

students performing a skit (note the banana-leaf glasses)

At times during our lectures or discussions a flock of ducks or chickens would wander through the classroom (which are located outdoors). This is so normal for the setting that a student normally stands up and begins herding the strays out of the class while everyone else goes about their business… 

Last week we were just barely able to make their graduation.  We flew back from State College, PA on March 4th, with layovers in Washington D.C.; Tokyo, Japan; Bangkok, Thailand; Maesot, Thailand, and then a few hours drive north to where we live.  Not all cylinders were firing – but we were extremely happy to see them receive their diplomas, to meet their extremely proud family members, and to participate in the ceremonies.  

On the students’ faces we saw a mixture of emotions.  They’re extremely proud of their accomplishments thus far, as they should be.  Many are worried about the future.  Now they have to go off and do something other than be students at KTBLC.  Uncertainty can be scary.  That uncertainty isn’t just for them at an individual level though; Karen State is changing at an increasing (alarming?) rate.  Fighting has mostly ceased, roads are now being built, electricity is reaching rural villages, new schools are emerging, development has finally come and that means the only certain thing right now is that some things will be different.  And that is the world that these students will be returning to.  They return as some of the most educated people in their respective communities and many of them will be taking leadership and public health roles in those communities, starting schools of their own, etc.      

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.

Change on the Thai-Myanmar border

It’s been several weeks since I last posted about moving my family to Thailand for my dissertation work.  We’ve all adapted quite well to our new home and I’ve yet to hear rumors of familial mutiny.

We’ve made a few trips to the closest city, Mae Sot, and once to a big malaria meeting in Guilin, China.  It is a strange feeling to come home to a place that seemed quite foreign only a few months ago, but now feels quite familiar.  When I told some people that we’d be moving to Thailand until at least March 2014, several commented on how long that seemed.  Now it seems like it is nowhere near long enough.  Each passing week I learn something new about the place, a new type of food, the names of mountains, villages and schools hidden down little dirt roads.  I have the Thai consonants and most of the vowels memorized and, now that I can read a little Thai, new worlds have opened.  Months of field work are certainly better than weeks, but it feels like a lifetime is necessary for me to really understand this place.

I haven’t left but I already miss the Moei River and the Dawna Range.  This place has certainly changed me and I think I’m safe in saying it will leave lasting impressions on my family too.

Big changes, little changes…

Things along the Thai-Myanmar border appear to be changing a lot.  To be fair, things here have always been in flux and that probably has a lot to do with this region's special place in malaria research.  Development has lagged in this region because of a half century worth of fighting between one of the major ethnic groups, the Karen, and the Burmese military.  Despite this political and military uncertainty, at least one place has emerged as an economic center in this part of the world: Mae Sot.  

Though it is nowhere near being the largest city in Thailand, it is one of the most multicultural.  Walking down its streets you see long-bearded Muslim men, Indian men with long, curled mustaches, Burmese and Karen people in beautiful sarongs (longyi) and frequently wearing thanaka on their faces, and a few NGO workers scattered about.  Thai street vendors sell noodles and soup in front of beautifully decorated pagodas and small street shops selling roti and samosas flourish across the street from a large mosque.  

The city is a center of trade, linking Thailand to not only Myanmar but also India and China.  Much of that trade is in illegal goods or through illegal channels, also lending to an interesting city vibe.  We are just south of the infamous Golden Triangle.  However the opium business here is apparently being exchanged for methamphetamine* and human trafficking thrives.  Early in the mornings there are several downtown stores that specialize in precious stones, especially jade, and they are always crowded with an interesting lot.  Crowds of the above described people, also including wealthy looking Thai men wearing enough protective amulets to make you wonder why they need so much protection, hover around brightly lit stalls.     

Since we’ve arrived here the Myanmar government has opened Karen State for tourism.  Previously some people were allowed to visit, but only after flying deeper into the nation, never over the border.  On the other side of the Thai-Myanmar Friendship Bridge lies the city of Myawaddy, and until now tourists were allowed to visit there only during daylight hours and were not allowed to travel deeper into the nation from this point.  That has now changed.  Also, over the last several years, there have been plans in place to connect Mae Sot to Moreh, India.  There are systems of roads across Myanmar currently, but they haven’t been kept in good repair in many areas.  The new push is an effort to create a new economic zone, with Mae Sot playing a key role.  

Where I live (Mae Tan), north of Mae Sot, things are apparently changing too.  People and goods have always moved back and forth across the Moei River.  The frequency (and legality?) of those movements appear to have changed.  Every day people come over from Myanmar and make their way down to the fresh market.  Some return on boats with bags of rice, eggs, fruits and vegetables.  Some carry toy trucks and bikes back across the border.  Sometimes suspicious trucks, full of cargo that I can’t see, make their way down to the river port around midnight.  This morning there are several full sized trucks, backed up to the river port, in full daylight, all while the border guards are on duty.  This is something new.  

But many people who’ve been a part of the conflict in this area or who have kept up with it are suspicious of some of these changes.  There is a questionable peace deal that has halted most armed conflicts between the Karen and the Burmese military.  However, not everyone has signed on to this deal, and for that matter, there is real question about whether or not it was actually a peace treaty or if it was just an agreement to begin considering a peace process.  Regardless, the Burmese military has come in to Karen state with new ease; they have paved roads and have resupplied their military bases.  If these changes aren’t well-intentioned, and given what continues to happen up in Kachin State many people are quite unsure, the Burmese military now appears to have a strategic upper hand.     

What will these changes mean for the ecology of infectious diseases?

I think it’s much too early to know, but I have some opinions.   While most of this region has a malaria problem, Mae Sot does not and has not for several decades.  An expert on malaria who has lived in this area for as long, told me in passing that when things like highways, concrete, and air conditioners arrive, the malaria seems to go away.  If economic changes are on the horizon, and they appear to be, then perhaps malaria will only continue to be a problem in small isolated pockets in this area.  Those trucks that I mention above are full of concrete bags which are being toted across the river.  It looks like environmental change is well on its way and I have quite complicated feelings about this.  

As someone who comes from a place with lots of luxuries that are either rare or nonexistent in the tropical world (running water, running water that you can drink, few deadly infectious diseases, etc.) I always feel like a hypocrite when I think that others shouldn’t go through some form of industrialization.  “Don’t cut all of your trees down.  We did that and now I wish we had them back” is an easy thing to say while sitting in front of a fancy computer in a climate controlled room.  The U.S. certainly wiped out malaria, but did we do so at a great environmental cost?  I don’t really know.  I hope that the answer to halting malaria isn’t that we must cut down all of the trees.  

Also, I’ve spent the last four years of my life focusing almost entirely on one infectious disease: malaria.  There are at least two reasons for this focus.  The first is that it is a major threat to global public health.  The second, and perhaps more practical, reason is that malaria isn’t something that you can really understand by just dabbling in it.  It is such a complicated disease that you really need to jump in and get wet from the literature, the laboratory work, and the field work to really be competent in it.  But in the hypothetical future when malaria is no more a problem for this part of the world, there will remain other infectious diseases.  Malaria mosquitoes don’t like concrete and streets, but dengue fever mosquitoes do.  Tuberculosis and HIV thrive on pioneer highways like the one that is soon to join Mae Sot to India.  Even if changing the environment does fix the current malaria problem, it won’t fix the current infectious disease problem: that is a problem of competing risks. 

Burma in my back yard

I’ve just recently begun my final stretch of field work for my PhD.  The last several years I’ve been travelling in the summers to the Thai-Myanmar border to do field work concerning malaria epidemiology and human demography.  This time I’ve moved my family, my wife Amber and my son Salem, to the field with me, and we’ll be staying until at least March of next year (2014).  We’ve settled into a cheap rent house in a town named Mae Tan in Tha Song Yang District, Tak Province and have spent the last several days trying to get it set up to our liking.  In fact, I’m writing this from my new home over the weekend with the hope that I’ll be able to post it while visiting the malaria clinic down the street (where I have internet access).

My new stove and the view out back of our rent house

From my kitchen window I can look out back over the Moei river, which marks the international border between Myanmar and Thailand.  Down one end of my block is an international border crossing and down the other is the malaria clinic.  While I’ve been working on my Thai, it does me little good in this neighborhood since most of my neighbors are Karen and they seem to know very little Thai.  

Across the Moei River from Tha Song Yang

Across the river there appears to be a simple mosque.  We can’t really see it, but there are several wooden, thatch roof structures and we hear the call to prayer several times during the day.  The river here is sandwiched by mountains on both sides and the resulting canyon makes a perfect echo chamber for carrying the sounds of the Imam’s song.  I don’t know whether the moslem adherents there/here are mostly Karen or if they are Rohingya who are attempting to flee persecution from the other side of Myanmar.  I do know that some of the Rohingya have been making their way to the refugee camps, one of which (Mae La, with about 50,000 people living in it) is a few miles south of here.  

A river ferry transporting someone across a very high Moei River

Over the last several days I’ve been struck by some interesting realities, a few that are related to research areas that I hope to investigate while here.  The most obvious to my family and me has been the openness of households…

Mosquitoes are most apparent at dusk and dawn, but if they get into your dwelling they’ll feed during the night too.  My toes and feet have been pretty thoroughly gnawed.  I brought a mosquito net for my son’s bed, and we’ve all been using some repellant from Mahidol University which appears to be made from lemongrass, but I’ve yet to find a net that will work for our own bed.  Furthermore, almost every house has openings that aren’t covered.  The tops of the walls in our bathroom and kitchen areas have ventilation holes large enough for me to stick my arm through – a feature which actually makes the humid bathroom and kitchen bearable in the humid heat.  

Such openings also make it quite easy for mosquitoes and other creatures to move into the house at will.  Last night we were awakened by a Tokay gecko, probably close to a foot long, that appears to have worked his way in as well.  If you’ve never heard a Tokay gecko’s call before, it isn’t something that is easy to ignore.  My son and I decided to name him Figaro, being that he so loves to sing.   

There has been some question about whether or not malaria transmission here occurs within households or outdoors, perhaps in agricultural fields.  For one species, Plasmodium vivax, infections appear to cluster in younger children.  I take this as potential evidence of exposure in or around the household, with older household members probably still being infected but having some acquired tolerance for vivax infections.  

Last night as I sat out front of my house, drinking a sweaty Chang beer, listening to the call to prayer and the rain that hasn’t stopped now for close to 3 days, I looked down the street and saw almost every household with doors and windows wide open, families sitting inside enjoying each other’s company.  If transmission is occurring within households, it’s going to be near impossible to completely stop.  I’m fortunate to have a relatively well built structure to stay in while living here and I can’t keep the mosquitoes out.  It is more than a little overwhelming to think about the options for the countless others who aren’t as well off as a poor graduate student.  

  

But even if exposure occurs outside of the household, and I think that for Plasmodium falciparum it does, it will be at least as hard to halt transmission.  Children cannot stay inside their beds or houses forever, it is healthy that they run and play outdoors.  Parents need to tend their agricultural fields, to hunt and fish, so that they can put food on the table.  

Another thing that has become blatantly clear is the effect of the rain on everyday life.  As I write this I believe it has been raining almost non-stop for about 2 ½ days.  The rains don’t make life come to a stand-still, but they do make things more difficult and uncomfortable.  The market was still open early this morning.  The steady stream of Karen migrants walking down our street continues.  A few hours ago I walked down to the border patrol check station, where migrants check in, and found empty, closed buildings (it is Sunday here) and a few boat drivers ferrying people to and from Myanmar from the Thai side of the border.  One jokingly asked if I’d like a ride across the river (and as exciting as that might be, it’s probably a bad idea).  When the Karen here were still at war with the Burmese military, fighting mainly occurred during the dry season – it is too difficult to traverse the countryside during the wet season.  

I frequently find heterogeneities in life to be fascinating fodder for research and theory.  Many of the statistical and mathematical models that population scientists, demographers, and epidemiologists use assume homogeneity in whatever processes we are studying: random mating, random mixing, random contacts, etc.  I think we all know that these things aren’t realities, but frequently that fact gets lost in the simple assumptions that are made, sometimes out of necessity, in research.  

Here I find some interesting heterogeneities in the rainy season.  While I complain that it has basically rained for several days straight, at times the rain slows.  During those times, traffic on the streets picks up.  This isn’t surprising, wading through puddles of muddy water isn’t fun.  Though the countless motorcycle drivers around here are quite adept at driving one-handed while holding an umbrella in the other hand, I imagine they’d much rather the rain stop altogether as well.  

And with the rains here comes malaria.  Tak Province consistently reports the highest number of malaria cases (both vivax and falciparum) of any province in the Kingdom, and within Tak Province, Tha Song Yang District has the heaviest malaria burden.  Cases here are highly seasonal, with only a very few in the dry season.  However, the trickle of infected people at the local malaria clinic isn’t a steady flow throughout the rainy season.  I once fancied a Poisson process of arrivals at the clinic, but this too doesn’t appear to be the pattern.  What is a pattern, however, is that after a rain, the clinic is quite busy.  (The clinic is closed on weekends and so Monday morning is generally a busy time too).  Does this mean that no one feels sick while it’s raining??  Probably not.  Also, it takes approximately 2 weeks from the time of infection until a person actually feels classic malaria symptoms.  So rain can lead to increased mosquito vector populations but infections that have occurred in the last day or two aren’t likely to be symptomatic so quickly.  No, it appears that people who are sick would rather not wade through muddy water, potentially have to illegally cross an international border, and then make their way down to the waiting area of a clinic during a torrential downpour.  

I think this makes perfect sense, but it doesn’t wind up in any model of seasonality in malaria infections that I’ve ever seen.  Rains = more mosquitoes = more malaria.  But rains also mean that people are likely to at least momentarily delay seeking treatment.  Infected people who wait longer before seeking treatment are important in malaria epidemiology because they spend longer amounts of time being infectious – potentially acting as so-called “super spreaders” (individuals who spread infectious disease at higher rates than do others).  

Adding the human context to disease ecology

Sometimes there exist subregions where, for a variety of reasons, diseases just tend to lurk and persist regardless of what is occurring in the surrounding regions.  An excellent example can be seen in Southeast Asia, where there exists malarious pockets surrounded by malaria free regions.  In Southeast Asia, these places tend to be hilly, forested regions and international borders.  For example, both Thailand and China have been relatively successful at eradicating malaria from much of their nations while continuing to have a malaria problem along their borders with Myanmar (also known as Burma).

So what is it about these places that make malaria eradication so difficult, at least on the China or Thai sides of the border?  Well, the simple answer is that it’s complicated.

This last summer I made a trip to the border between China and Myanmar to visit one of the field sites we are using in our malaria research.  My trip to Nabang, China began in Kunming (the capital of Yunnan Province), where I caught a plane to Tengchong and then caught a five hour ride through steep mountains to the relatively small border town called Nabang.

Directly across the China-Myanmar border from Nabang is a town called Laiza which at one point was a tourist attraction for wealthy Chinese, offering a legal gambling outlet.  Today the fancy new gambling halls are still up and running in Laiza and there are several relatively nice hotels in Nabang, both mostly empty and waiting for the tourists to come.  Lining the streets of much of Nabang are brand new, fancy looking street lights, none of which have ever been turned on.  Nabang has the feel of a Wild West gold mining town after the gold is all gone.

So what happened to this place?  Basically, war happened.

Downtown Nabang, with Laiza in the distance.

Laiza, which is in Kachin state, is named after the indigenous group (the Kachin) that has historically lived in this region of Northern Myanmar.  The Kachin are known for their fighting skill, they were our allies in this region during WWII, and they have historically been at odds with the ruling national government.  In 2011, after a 17 year truce, civil war broke out between the Kachin and the government military.  Unless you’re familiar with this region though, you’ve probably never heard of this war.  This isn’t the type of shock and awe war that we all saw when the U.S. went to war with Iraq or even the high-level shelling currently occurring in Syria.  Villages get burned in the middle of the night, women and children are kidnapped, raped and forced into labor, and military camps are occasionally ambushed.  It is a low grade, slow-and-steady war that claws at the psyche of the people living in this area.   

The KIA (Kachin Independence Army) is currently located in the Laiza Hotel, right in the middle of what was once a tourist retreat.  

What does this mean for the human ecology of the place?  

For one, it means that many people are clustering up near the border in make-shift camps for ‘internally displaced persons’ (what you’re called when you’re a refugee in your own nation).  When I was there, the people living in camps were working together in preparation for many more people to arrive.  

Villagers preparing for new people to arrive.

It also means that the population has a very unique composition, made up mostly of women, children, and the elderly.  Working aged men were mostly absent, except for the occasional young adults that would zip by on their motor bikes, donning camouflage and carrying AK47s.  Instead of helping out with household chores and working in the near-by agricultural fields, the men are moving covertly through the mountainous and forested landscape, engaged in warfare with the Burmese military.    

A KIA soldier riding through town.

And what does this mean for the disease ecology of the place?

By disrupting the everyday lives of populations, conditions are primed for disease.  Close-quarters mean that easily transmittable diseases will almost certainly move through the population rather than be confined to individual households.  Diarrheal diseases that are common in children may become a problem for everyone.  The same is true for airborne diseases such as influenza and tuberculosis.  For already stressed and sometimes malnourished people, this is an added threat.

Furthermore, vector borne diseases are an increased threat.  Newly cleared fields easily form water puddles when it rains, making excellent breeding grounds for mosquitoes.  Dengue fever could easily thrive in these camps.  And for a variety of reasons, malaria is already a growing problem.  

Some preliminary research in this area has indicated that working-aged males appear to disproportionately acquire falciparum malaria infections.  Given that most of these working aged males are living in the conditions of war, moving through the jungles at night, sleeping out-doors, and almost constantly being exposed to a range of mosquito vectors, perhaps this is no surprise.  

And what happens when they are too sick to fight?  One could imagine that they then come home, with a thriving population of parasites swimming in their blood.  A potential real danger, and one that my research is particularly aimed at, is that these individuals could then pass the disease on to their families and neighbors. 

Also, given that artemisinins have been available in Myanmar and China for decades, and since there clearly is no regulation of their use in Myanmar (especially in this part of the nation), conditions are also primed for drug-resistant parasites.  We are already seeing this on the Thai-Myanmar border, it isn’t a stretch to expect to find it in this region next.  

And if these pretty terrible conditions weren’t bad enough, there is another disease that has predominated in this area for some time.  It is a hotspot for HIV/AIDS –because there are thriving sex and opium trades.  (Note: The sex and opium trade bring in problems of their own, even outside of infectious disease.)  Much of the world has been privy to the knowledge about where HIV/AIDS comes from, how it is spread, and how to keep from becoming infected.  However, Myanmar has been largely closed to the world until the last several years, meaning that such educational campaigns are unlikely to have reached many outside of the wealthy, urban, or elite of this nation.   

What does this all of this mean for public health efforts?  

Clearly this isn’t an easy place to work.  It isn’t even an easy place to get to.  Our collaborators at Kunming Medical University have sent several teams of graduate students to the field sites here in order to collect demographic and epidemiological data.  Many of them don’t stay for long.  It is a depressing environment, there are frequent earthquakes, the heat is almost unbearable and AC units don’t work when the electricity is out.  Oh… and it’s a war zone.   This makes getting data difficult, and given the fluctuating population size and composition, it makes epidemiological modeling difficult.  This means it is really hard to fully understand the disease situation.  

The hospital in Nabang, China has been badly damaged by earthquakes.  Here it is being repaired and expanded.  This hospital sees a lot of malaria cases as well as wounded soldiers from the fighting.

Not all malaria endemic places in Southeast Asia are the same but there certainly are some commonalities.  Another malaria endemic border zone, along the Thai-Myanmar border, was until very recently also a site of ethnic tensions and occasional war.  The Thai-Cambodian border zone was a strong-hold for the Khmer Rouge up until the 1990s.  It was also a site of heavy, informal mining efforts, which led to living conditions that appeared very similar to the refugee camps I’ve seen in Northern Myanmar on the Chinese border.  Perhaps a common theme across these regions is the disruption of ‘normal’ human ecology.  These are places where people haven’t had the chance to settle in, to develop their homes and villages, and to fix problems associated with sanitation and hygiene.  

Perhaps it is too much to think that some of these regions will ever be malaria free.  But I can’t help but think that conditions would be much more controllable, perhaps even with a low, maximally acceptable, background level of malaria, if only the socio-economic and political conditions weren’t as they are.  And while it’s easy for me to say that if we could just stop warfare and fix poverty that we’d have a lot more success at controlling disease, clearly doing these things isn’t anywhere near easy.  However, these challenges can’t even begin to be approached until there is a widespread realization that these are in fact the underlying, downstream conditions that lead to bad human health outcomes.  

Main road through one of the study villages near Laiza, Myanmar.