Health workers carrying out malaria control activities - sometimes covertly - in conflict zones along the Thai-Myanmar border hope additional donor funding will help reduce infection rates that have remained almost impervious to health services.
“If the [malaria control] programme is done efficiently, and people are given access to the basic tools to reduce malaria, then this will help to overcome malaria across the region,” François Nosten, head of the Shoklo Malaria Research Unit's clinic on the Thai-Burma border, told IRIN.
“There has been a huge reduction in malaria, but we need continue to make sure those inside Myanmar are getting the necessary resources to prevent themselves from becoming infected.” Nosten anticipates a boost in funding to fight malaria along the Thai-Myanmar border from the United States Agency for International Development (USAID).
Between 2002 and 2009 the Burmese government reported a continuous reduction in the number of reported malaria deaths from 2,634 to 1,088 and admissions for malaria treatment at health facilities dropped from 82,193 to 47,772.
However, these gains were not evenly distributed. “In the areas with the highest burden, infrastructure is not well developed and transport often has to be on foot. Furthermore, the control of some areas by local ethnic groups constrains the operation of public services,” the World Health Organization (WHO) noted in a national 2011-2015 malaria control strategy document.
USAID announced plans in December 2011 to expand a regional malaria control project into “hard-to-reach border areas”, including Mon and Karen states in Myanmar, “depending on access”. In its 2012 operational plan the proposed regional budget covering six countries in southeast Asia is US$12 million, with an estimated 40 percent going to Myanmar, 20 percent to Cambodia, 8 percent to border areas in Thailand, and 32 percent for regional support activities.
Evidence surfaced at least 8 years ago that the malaria parasite was becoming resistant to artemisinin in the currently recommended treatment cocktail for malaria, known as artemisinin combination therapy (ACT). Studies showed treatment time was taking longer and costing more.
The USAID-funded project applies similar strategies to combat a malaria epidemic on the Thai-Cambodia border, including the mass distribution of bed nets, malaria prevention education in communities, and improving access to remote populations.
Health experts have identified three tiers of "hotspots" in Myanmar. The highest priority is given to the 10 townships in Thanitharyi Division in the south, along the western Thai border, and Shwe Kyin township in Bago Division East. Tier 2 (unclear evidence of suspected resistance) includes all of Kayin (also known as Karen), Kayah and Mon states, and the rest of Bago Division East. Tier 3 is the rest of the country.
While ethnic groups have fought for more autonomy, health workers have struggled to survey health provision, including combating malaria, in the dense jungles of Karen State, said Saw Eh Kalu, a border health worker with the NGO Karen Department of Health and Welfare (KDHW), which is run mostly by Karen exiles operating from Thailand near the Burmese border.
With funding from the US-based NGO, Global Health Access Programme (GHAP), KDHW has trained health workers who have illegally crossed the border to work in some 200 remote villages, housing close to 50,000 people.
“By setting up this network of village health workers, we have been able to dramatically decrease the level of malaria inside Karen State by treating people faster and more efficiently,” said Saw Eh Kalu. Health volunteers have cut down on the often-fatal treks to get to a health facility for treatment, he added.
Communities in conflict areas have also organized “malaria control committees” of village leaders, school teachers and others to help with bed net distribution and malaria education. When GHAP launched its programme, it estimated that 12 percent of Karen State’s population had malaria. After six months, prevalence decreased to between 2 and 6 percent, according to the NGO.
The Karen National Liberation Army and its political wing, the Karen National Union, have engaged in ceasefire talks with the Burmese government in recent months. On 7 April, Myanmar’s President Thein Sein met with Karen leaders and agreed to a ceasefire, which both sides, despite flare-ups, have respected.
“The conflict makes it very hard and dangerous for us to reach communities most affected by malaria,” said Saw Eh Kalu. “If these ceasefires remain in place, it will make it easier for us to access remote communities and make our programmes more efficient at reducing malaria.”
Linda Smith, programme director of infectious disease at GHAP, which works closely with KHDW, noted that timing is critical. “As resistance to the artemisinin drug grows, it is an important time to increase funding and coverage,” she said. “And regardless of [drug] resistance, donors need to be sustaining funding to keep malaria down and prevent resurgence.”
The government launched the Myanmar Artemisinin Resistance Containment Project (MARC) in 2011, surveying households, health facilities and drug outlets.
Preliminary survey data has started providing a clearer picture, but WHO malaria expert Pascal Ringwald said there is a need to boost funding, to “better map the situation” in Myanmar.
Smith noted that a benefit of increased funding from USAID and others will be greater collaboration between groups working inside Myanmar and border organizations, which are often affiliated with ethnic rebels and have long been disconnected from the work carried out in Myanmar.
“The project will help to overcome past antagonisms and prejudices between the two groups, which will be important, since neither approach alone is sufficient to reach all the populations at risk.”