On the Road: Malaria Elimination Efforts in the Greater Mekong Subregion
By Susan Byrnes and Anjali Kaur
In the lush, remote countryside about three hours south of Bangkok, as the day edges towards dusk, a steady flow of migrant workers trickles across the border from Thailand to Myanmar, also known as Burma. They come straight from the farms, shops and small factories that line the roads around the border crossing, heading back home to the children and families who live on the other side.
Many of them, like 20-year-old Li Li Nai, are day laborers who live in Myanmar, but come to Thailand for work. Nai is in her second week on the job, sewing sneakers shoulder-to-shoulder with dozens of other young women in a small factory.
“I’ve been working here for two weeks,” she says. “I don’t have work in Myanmar.”
This forested border community, and similar ones across Cambodia, Vietnam and Laos, provide the backdrop for two compelling – and seemingly opposite – narratives about the malaria fight: undeniable progress in reducing cases and deaths, and the looming threat of parasite resistance to the most important malaria drugs.
The progress is stunning. Over the past 15 years, there has been a steady decline in malaria cases and deaths in the Greater Mekong Subregion (GMS), with a 35 percent reduction in cases and a 30 percent reduction in the annual number of malaria deaths. Clinics that used to treat many patients per day can go a week with only one or two cases of malaria.
Even in the most remote plantation homes, people know to sleep under insecticide-treated bed nets. Health workers supported by organizations like Raks Thai Foundation, are trained in malaria prevention, diagnosis and treatment live or work in border communities and provide service to the villagers.
But the fluidity of the population and the stubbornness of the malaria parasite make these areas some of the most challenging places to eliminate malaria for good. The highest transmission of malaria in the GMS takes place along borders and in remote forests. Also, the species of malaria parasite that causes most deaths in the region – Plasmodium falciparum – has shown resistance to several anti-malarial drugs. The GMS is actually the birthplace of antimalarial drug resistance, starting with chloroquine resistance developing in the late 1950s.
In another border community, Ab, 33, pours buckets of collected rubber into molds, scraping the top to create a smooth edge before the rubber forms. Plantation workers tap rubber in the cool of night – the same hours that the disease-carrying mosquitoes bite. As the sun heats the air to a thick steam, Ab is finishing his work, collecting it in buckets, molding it, pressing it and hanging it to dry.
“My sister and brother have had malaria. The symptoms are quite serious,” he says. “I am afraid to get bitten. We are all afraid of malaria.”
Rung Bunkok, who runs a private health clinic several hours outside Phnom Penh, Cambodia, has seen the dramatic decline in malaria cases over the past decade. These days, he only sees a handful of cases per month. But some of the cases trouble him greatly. He treated a patient recently for P. Falciparum and month later, he was back at the clinic and tested positive again. The local organization Population Services Khmer works in partnership with providers like Bunkok to ensure approved malaria drugs are available in areas that are high-risk for malaria transmission.
“I’m really concerned about drug resistance,” he says. “People are so mobile they move from one place to another. It is very difficult to treat malaria when people are moving around.”
Cambodia represents the geographic epicenter of emerging malaria strains that are becoming resistant to anti-malarial drugs. The spread of these resistant parasites would threaten recent successes in malaria control and jeopardize the gains made to date across the malaria-endemic world, particularly in sub-Saharan Africa.
As a result, a number of organizations are prioritizing elimination in the GMS as key to global malaria elimination. The World Health Organization launched a new strategy in 2015 for malaria elimination in the Subregion, and the Global Fund to Fight AIDS, Tuberculosis and Malaria launched a three-year $100 million Regional Artemisinin Initiative to reduce malaria transmission.
The U.S. government has also supported malaria control efforts in the GMS since 2000, focusing on antimalarial drug resistance monitoring and drug quality surveillance. If proposed funding for the President’s Malaria Initiative is approved by Congress, the U.S. will launch an effort to eliminate malaria in Cambodia together with the Cambodian government, NGOs, and other partners.
We are hopeful that with this kind of urgent focus and support, we can move one step closer to ending this disease for good.
Susan Byrnes is Managing Director, Strategic Communications, Anjali Kaur is Director of Asia.
1. WHO Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030).
Image: Rung Bunkok takes inventory of the malaria medications at his private clinic in Tbong Khmum province in Cambodia. Source: Haley George