RANGOON — After decades of fighting between the national military and ethnic armed groups, the country’s reformist government has faced a major challenge of building trust with people in Burma’s ethnic border states.
As the war in Kachin State rages on and clashes continue to erupt, despite ceasefires, in several other ethnic minority regions, local civilians still live in fear of the military and say Naypyidaw’s peace negotiations have produced few results.
But if political talks have not yet established trust in border states, another model may be emerging in the public health realm, as the government, the military and the civilian sector come together to fight an increasingly worrisome problem: drug-resistant malaria.
Burma has one of the highest incidences of malaria in Southeast Asia. The disease is especially prevalent in border states, whose lush forests have not only sheltered government troops and ethnic rebels at war, but have also served as breeding grounds for mosquitoes.
Now, as the country transitions to democracy after nearly half a century of military rule, public health researchers say collaboration, including with military scientists and doctors, could help the government, medical universities and NGOs advance efforts to eradicate the disease.
“The military population is quite significant in Myanmar [Burma], and they probably have a lot of capability because they’re stationed in places where most people can’t reach,” said Dr. Myaing Myaing Nyunt, a malaria researcher who has spent years studying the disease in Burma, often collaborating closely with the Ministry of Health.
The country’s military doctors already treat thousands of malaria cases, according to Dr. Christopher Plowe, a professor at the University of Maryland School of Medicine who is now working with Myaing Myaing Nyunt in Burma after leading a malaria study with the World Health Organization (WHO) and other scientists on the Thai-Burma border, Bangladesh and Cambodia.
“If they had enough of a support system and could approach it in a right way, they would be able to provide health care for people in hard-to-reach areas,” said Myaing Myaing Nyunt. “They can work with the civilian sector and help provide care to the populations. In malaria [eradication], they’re already doing it.”
With grants from the US National Institutes of Health, Myaing Myaing Nyunt and Plowe, who are married, have invited about 80 malaria researchers from the ministry, local universities, NGOs, the military and the international community to a workshop in Burma. Starting on Monday, the workshop will include hands-on training in lab techniques to study drug resistance in the country.
“Malaria is a perfect catalyst to bring people together,” Myaing Myaing Nyunt said. “The military is interested, the local population is interested and the national and regional governments are interested. It’s a social disease; everybody cares about it.”
‘Running Out of Options’
Burma is home to about 3 percent of Southeast Asia’s population but about 20 percent of the region’s malaria, said Plowe, citing WHO statistics.
Eradication efforts are becoming more urgent because some malaria strains are growing increasingly resistant to the most effective treatment, artemisinin-based drugs, which means the drugs take longer to clear the parasite from the blood stream.
Francois Nosten, head of the Shoklo Malaria Research Unit in the Thai town of Mae Sot, on the border with Burma, said growing resistance to artemisinin-based drugs was a regional issue that was believed to have started in Cambodia.
Malaria parasites in the region have formed resistance to other drugs in the past, including affordable chloroquine treatments, and that resistance spread to Africa, which has some of the world’s highest rates of malaria mortality.
“There’s nothing to replace artemisinin yet,” said Nosten, who helped publish a report in April showing the emergence of drug resistance on the border, and who was among a network of researchers in Southeast Asia who sent Plowe medical samples for the WHO-supported study.
He added that two or three new drugs were under development but would probably not be ready for years.
“We’re worried that we’re running out of options for treatment. … The strategy is to try to eliminate malaria before resistance becomes too serious,” he said, noting that malaria cases on the Thai-Burma border were reduced to an “all-time” low last year, with just a few hundred cases reported at five clinics.
Back to Burma
In Burma, over 40 million people, or an estimated 69 percent of the population, live in malaria-endemic areas, according to WHO.
The problem has brought Myaing Myaing Nyunt back to the country following years overseas.
Born in Burma, Myaing Myaing Nyunt went abroad after the violent military crackdown on nationwide pro-democracy protests in 1988, while she was studying as a medical student in Rangoon. She eventually immigrated to the United States, where she graduated from medical school, earned a PhD and became an assistant professor at the Johns Hopkins Bloomberg School of Public Health, where she continues to work today.
With much of her family still in Burma, she went back to Rangoon for the first time in 16 years when her father died in 2004. After making contact with local scientists and exploring possibilities for collaborative work, she returned again four years later, this time with Plowe, for public health research.
“We started talking with scientists there, who were my old friends and old colleagues, who knew my family and knew me a little bit,” she said.
Plowe made headlines recently after the WHO-supported study on the Thai-Burma border, in Bangladesh and in Cambodia proposed genetic markers to identify which strains of malaria were resistant to drugs, potentially making it possible to track the spread of resistance and focus eradication efforts on areas where it is most prevalent.
At the workshop next week, he and Myaing Myaing Nyunt will work with local investigators to replicate that study inside Burma.
The Military and Malaria
Until recently, international collaboration in research or public health was extremely limited in Burma, Myaing Myaing Nyunt said, as economic sanctions created a challenge for funding in the long-isolated pariah state.
“It was hard to do research because there weren’t good resources, there wasn’t much investment in training, and the younger generation [of medical providers] didn’t have access to international research,” she said. “There are too many other priorities in health care.”
Since the military junta handed power to a nominally civilian government in 2011, public health workers from the ministry, universities, NGOs and the military have been working together to study diseases through research projects, conferences and training sessions.
In other countries, the military has long assisted with public health research, she said.
“In Cambodia, for example, military researchers are investigating malaria, and the US military is out there helping them,” she said. In Mali, where she and Plowe also helped train local health professionals, she said the US military has provided training and capacity building to fight malaria, tuberculosis and HIV.
“They [military institutions] are also great at helping establish IT and data systems,” she said. “We have to remember, military personnel are very disciplined, they know how to follow orders and many of them are very well trained.”
With stronger US-Burma diplomatic ties, American military scientists could provide similar assistance in Burma, she added.
“It would only be a good thing for the people of Myanmar, particularly for disease control,” she said.
But malaria eradication is just one area of public health where Myaing Myaing Nyunt hopes collaboration among various groups will grow in Burma.
With a grant from George Soros’ Open Society Foundations, she has spent the past six months helping the Ministry of Health improve Burma’s medical education and research, despite its low budget, by harnessing the resources of local NGOs, international organizations, universities and the private sector.
“It [collaboration] could be for malaria, or environmental health or bioethics,” she said. “Any pathway that would make medical and public health education push their standards to the level of international standards.”
As part of her work, she is planning a project that would allow young medical students to spend time in community outpatient clinics, observing professional doctors at work and hopefully learning how to form respectful and trusting relationships with patients.
“This is nothing new—it’s been going on in the US, the UK and many Asian countries, but it hasn’t been a practice in Myanmar,” she said. “This would be the first time that university students [here] would be working with physicians from outside private organizations or private clinics.”
Collaborating with universities and the Myanmar Medical Association, the largest network of private doctors in the country, Myaing Myaing Nyunt is preparing to propose the project to the ministry, and with approval she hopes to launch a pilot program with a small group of students by 2014.
Other public health researchers have also noticed greater openness in Burma since 2011.
Vit Suwanvanichkij, a public health researcher who has worked extensively with displaced Burmese migrants on the Thai border for more than a decade, visited hospitals in Burma under the former military regime and again last year.
“In the past, [health] staff wouldn’t meet with me, or if they did, they were very guarded,” he said. “And when I visited government hospitals, I was usually asked to leave, as foreigners were forbidden to visit without prior permission.”
In his trip last year, Suwanvanichkij said he noticed a more “discernible openness toward discussing health problems in the country.”
At hospitals, “in contrast to the past, I was shown around, able to meet some patients, see some of the public health records collected, and hear directly about some of the problems” he said.
“The atmosphere has changed. I think it has to do with a more open environment to talk about some longstanding problems, such as health, in Burma.”
Burma was ranked second-worst in the world by WHO for its overall health care system under the military junta in 2000, and its government today continues to be among the lowest spenders on health care as a percentage of gross domestic product.
Suwanvanichkij added that there remain many hurdles. One of the biggest obstacles to working with local health groups, including those operating malaria treatment and control programs, particularly in rural ethnic areas, is the Unlawful Associations Act, he said.
“If you’re meeting with any group that’s not officially registered, you could face jail time, which deters many public health officials from working with unregistered groups, including health organizations,” he said.
“We need to identify very urgently the structural problems [in public health] so we can talk about them and start addressing them, especially now that there are signs of malaria resistance increasing in Burma,” he added. “We don’t have time to wait.”