Malaria, despite being preventable and treatable, still kills over half a million people every year globally. While astonishing progress has been made in the past 15 years, with more than 7 million malaria deaths averted and about a 40 percent reduction in malaria globally, the fight is now inching towards a tipping point. Progress has slowed down in some parts of the world and reversed in a few.
A major challenge confronting malaria elimination is the emergence of drug-resistant malaria in the Greater Mekong Subregion, including Thailand, Cambodia, Myanmar, Laos, and Vietnam.
“This area is the epicenter of drug-resistant malaria. Drug-resistant malaria can become a global health threat if we cannot manage and eliminate drug-resistant malaria in Thailand and the GMS," said Thailand’s Minister of Public Health, Professor Piyasakol Sakolsatayadorn. “The region has long been an epicenter of antimalarial drug resistance. In fact, 40 to 45 years ago, chloroquine resistance had spread throughout the world from this region. So, there are fears about risk of re-emergence of malaria because of anti-artemisinin resistance.”
If drug resistance from Greater Mekong Subregion (GMS) spreads beyond this region, “it will have a devastating impact on countries with high burden of malaria" said Alistair Shaw, Senior Program Officer, Raks Thai Foundation, a successor to CARE International Thailand.
But science at best is inconclusive if the spread of drug resistance is at risk. Tim France, a noted global health expert, who also leads Inis Communication, agreed: “At present, you can say largely that there is more that we do not understand about malarial drug resistance and we do know we are at a very active learning period. But at the end of the day, whether drug resistance is spreading or occurring de novo, the conclusions and essential actions remain the same."
Governments promised to end malaria
In 2014, 23 Asia Pacific heads of governments committed to eliminate malaria in the region by 2030, in line with the UN Sustainable Development Goals (SDGs). Thai health minister Piyasakol reaffirmed that the country is on track for ending local transmission nationally by 2024.
Thailand’s National Malaria Elimination Strategy was endorsed in 2016. Since then, malaria cases have continued to decline: from 2012 to 2017, the number of malaria cases in Thailand fell by 67 percent, with a 39 percent drop between 2016 and 2017. In 2017-2018, malaria cases in Thailand further dropped by 51 percent, from 14,684 to 7,153.
Challenges confronting the fight to eliminate malaria
Thailand is not only moving towards malaria elimination by 2024 but also making progress towards sub-regional elimination targets within Thailand, according to Shreehari Acharya, Project Manager, Regional Malaria CSO Platform. Last year on World Malaria Day 2018, Thailand declared 35 provinces (of 76) malaria-free. But malaria is concentrating towards Thai borders, making the fight to end the disease even more complex.
“As we slowly move towards elimination of malaria in Thailand, the cases continue to shift closer to borders and more hard-to-reach mobile migrant populations,” said Alistair Shaw of Raks Thai Foundation.
To fortify Thailand’s goal of eliminating malaria from within its border and from the Greater Mekong Subregion, the Global Fund to fight AIDS, Tuberculosis and Malaria pumped in the largest multi-country regional grant of US$243 million to accelerate elimination of drug-resistant malaria from 2018 to 2020.
“Our role has been to create malaria resilient communities who can identify themselves when they suspect malaria cases and can respond to it through all the different mechanisms that have been set up and the links that have been made to health services,” said Alistair Shaw. “We have also made strong relationships with the local government officers to conduct mobile testing and prevention education in vulnerable populations which include mobile migrant populations from Cambodia, Vietnam, Laos, and Myanmar, as well as mobile Thai ethnic minority communities traveling through forests or across borders for various activities.
The problem is extending the reach of the government services to communities that are located very far from local government health services and do not feel comfortable, or are unable, to access a conventional health service. Accordingly, Malaria testing and treatment is free for all people in Thailand including those who are not Thai nationals.
Migrant workers who come to Thailand are normally covered by Thailand’s disease control programme and they get access to malaria clinics. But Shreehari Acharya said they're having difficulty about access because, as she said, “Although the services are free, all mobile migrant populations may not necessarily be able to access them.”
In some malaria high-risk border areas, there is no internet access, no mobile network, and/or no public transport, making access to health services more difficult. Another barrier to healthcare is faced by those mobile migrant populations who have a language barrier and/or do not have legal documents. They are still not comfortable to go alone to a health facility. They need someone whom they can trust, and who speaks their language, to accompany them.
Government health facilities are at times understaffed. Hence government staff may not be available to accompany civil society to go to the forests or farms and provide health services to high risk populations.
However, as Thailand moves towards malaria elimination, said Jetsumon Sattabongkot Prachumsri: “As malaria cases decline, people’s awareness also declines, especially in areas that were malaria-endemic in the past.”
For example, Kanchanaburi province used to be malaria endemic with malaria in every district, but now it has fewer than 30 to 40 cases and that too not in every district.
“Youngsters born in a district that now has no more malaria cases do not know about malaria,” Jetsumon said. “But the older people might still carry the parasite asymptomatically inside them and be the reservoir of malaria transmission. We cannot let down our guards, otherwise re-emergence could happen.”
Greater collaboration is needed to improve surveillance, especially along the border sites. As countries implement malaria elimination programs, surveillance becomes more important to prevent re-emergence.
“We also need more clarity on roles civil society can play in malaria surveillance," said Shreehari Acharya.
Malaria elimination is possible through raised awareness. Everyone needs to understand that malaria is transmitted by the vector and that some of the people may not have any external symptoms but can still harbor the parasite and can transmit malaria.
"We need to make all malaria and other essential services available as near as possible to the community,” said Shreehari. “Also I think the community at the village level is best placed to effectively provide these services, as civil society volunteers or someone trained in the community should be able to test and treat malaria unless medical attention is indicated (like malaria in pregnancy or other severe cases require medical care).”
Shobha Shukla and Bobby Ramakant write for Citizen News Service