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. 

Disease driven poverty

In a few of my previous blog posts I’ve discussed the relationship between poverty and infectious disease.  Many of the most prevalent and severe infectious diseases in the world disproportionately affect the world’s poor.  Part of the reason is that the necessary resources aren’t available for tackling such diseases.  A lot of money is currently spent (wasted?) on designing biomedical ‘cures’ for diseases that persist in some places (usually economically poor places) while having already been eradicated in other places (usually economically rich).  It is my position that diseases such as malaria and tuberculosis remain major threats to some populations simply because of the way that financial resources are allocated in our extremely heterogeneous world.

But there is another angle to this story.

Not only does poverty lead to poor health, but poor health can also lead to poverty.  Quite frequently, that is, the arrows point both ways and the reality is a system in which there are “positive” feedback loops.  There is a growing literature on this type of system which is frequently referred to as a “poverty trap.”  Much of this literature has been in economics, where mathematical models have indicated that populations with infectious diseases are less able to ‘develop’ economically.

With economic development at the population level, e.g. with the growth of average income levels, we tend to see an increase in overall life expectancy at age 0.  Most likely this indicates a relationship between improved health and increased wealth.  However, most of the models that actually look at this relationship are either ecological (they are looking at the entire population and frequently assume homogeneity within the population) or at an individual level.  A few models have also looked at community or household levels.

One major problem with models of all types is that results can change when we change our unit of scale.  The effects of poverty on disease, for example, might be different if we look at a community level rather than a province/state level or even consider an entire nation to be a single population.  This is a problem known as the ecological fallacy (and is closely related to the modifiable areal unit problem) in which causal relationships at the population level don’t explain what is happening at, say, the individual level.  

Regardless of these problems and issues, there does appear to be a feedback loop between poverty and disease.

And this is an interesting thing from an anthropological view.  First off, poverty can mean different things to different people.  For example, to some, poverty means “not modern.”  Some indigenous groups actually choose to live in a traditional house rather than a more modern one.  In my opinion, “traditional” (or not modern) does not equal poverty, but it does get mistaken as poverty.  Poverty can also be a relative thing; something that becomes apparent when you don’t have as much stuff as the people with whom you are coming into contact.  Clearly this may lead to psychological and sociological issues, but it might also explain gradients in outcomes (relative health?)  Finally, there is a type of poverty that exists where people are simply unable to put food on the table.  While there can be some argument about the effects of modernization and relative poverty, I would suggest that this final type of poverty is unambiguous and its negative effects are less debatable.  

In poverty trap models we are frequently interested in investigating and understanding threshold levels under or above which equilibria are reached.  (There are quite a few relatively new papers out that are excellent references (see: Bonds, Keenan, Rohani, & Sachs, 2010; Plucinski, Ngonghala, Getz, & Bonds, 2013; Wood, n.d.)).  Perhaps it is easiest to consider at the unit of the household.

An already poor or marginally poor household in which the major breadwinner is afflicted by severe disease is plagued with multiple problems.  For example, aside from the risk of infection for other household members, if that person is afflicted by malaria or dengue fever, they may not be able to work for several weeks.  A house on the margin of poverty may then fall just enough behind in household money and/or food to fall into true poverty.  Households that are already poor may fall even further.

And an important aspect of this situation is that not only is the person who is actually infected met with further troubles; the entire house is also afflicted.  Furthermore, there tends to be heterogeneity in these effects even within households.  That is, poor households may see things such as greater infant mortality, and this effect may be exacerbated when there is a shortage of food or resources in the household.

In poverty trap models, there are usually equilibrium points in poverty levels that, once reached, are quite difficult to break.  From Bonds et al. (2010):

What may be most important in these debates is therefore not whether the effect of health on poverty is more significant than that of poverty on health, but whether the combined effect is powerful enough to generate self-perpetuating patterns of development or the persistence of poverty.  

Children who grow up in households with frequent food shortages may not have the same physical or cognitive abilities as others.  Their immune systems, already taxed by years of exposure to pathogens, may not be able to fight off diseases as well as their healthy counterparts.  Therefore, when they begin their own households, they are already behind in the nutrition, health, and economic game.  And once again, when adults in the new household fall ill and cannot put food on the table, the children will be disproportionately affected.  

This cyclical pattern, where disease leads to poverty and poverty can lead to disproportionate disease, provides a perfect storm in which there aren’t enough resources to keep from getting sick, where once sick you are likely to fall further into poverty, and once you fall further into poverty you are even further away from pulling yourself and your family out.  This leads to the maintenance of poverty and sickness across the generations.

And this story could perhaps get even more complicated when we consider some evolutionary implications.  For example, populations that have historically been afflicted with malaria also tend to have high proportions of blood and blood-related disorders that seem to protect against malaria.  Almost all of these disorders are harmful in some cases (for example, in homozygotes).  Therefore the evolutionary history of disease can lead to a situation where some individuals are actually plagued with sickness from the very beginning of life.  Paradoxically, under situations of heavy malaria burden, some people with these disorders will apparently be healthier than their non-affected counterparts.  I don’t know whether the side effects of these disorders are enough to lead to poverty traps on their own.

Finally, in an age when many scientists appear to be looking “for the gene for (fill in your favorite thing to study)”, poverty traps and households are an interesting thing to ponder.  Poverty and the apparent predisposition of household members toward succumbing to disease can look like a genetic effect.  If it runs in families, and certainly both poverty and sickness do, then it can look a whole lot like there is a genetic reason for it.  I think that poverty trap models are therefore a nice illustration of how we could arrive at the same phenotype (poverty and sickness) from purely socio-economic and ecological factors.  

REFERENCES:

Bonds, M. H., Keenan, D. C., Rohani, P., & Sachs, J. D. (2010). Poverty trap formed by the ecology of infectious diseases. Proceedings of the Royal Society B: Biological Sciences, 277(1685), 1185–92. doi:10.1098/rspb.2009.1778

Plucinski, M. M., Ngonghala, C. N., Getz, W. M., & Bonds, M. H. (2013). Clusters of poverty and disease emerge from feedbacks on an epidemiological network. Journal of The Royal Society Interface, 10(80), doi: 10.1098/rsif.2012.0656.

Wood, J. (in press). The Biodemography of Subsistence Farming: Population, Food and Family. Cambridge University Press.

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.