2[1].4 Project Background Reading - Health

2.4 Project Background Reading -- Health Malaria, Drug-Resistant TB Flourish in Myanmar by Ed Cropley, May 30, 2007 MAE SOT, Thailand (Reuters) - Simmering civil war, fake drugs and a non-existent health service in Myanmar are creating the perfect breeding ground for new, drug-resistant strains of killer diseases such as malaria and tuberculosis. While the most immediate threat beyond Myanmar's borders is to Thailand, home to a large migrant and refugee population from the military-ruled former Burma, the long-term implications of neglect could be felt right across the globe, experts say. At stake is a Chinese drug called artemisinin, the world's most powerful weapon against malaria, a disease that kills more than a million people a year, most of them children in sub-Saharan Africa. The drug is most effective when used with other treatments in what are called artemisinin-based combination therapies (ACTs). But doctors say taking ACTs incorrectly or in doses that include fake pills is one of the easiest ways of allowing the mosquito-borne parasite which causes malaria to build up immunity. Such behavior appears to be commonplace, Thai health officials say, in Myanmar, where health spending is only a few dollars a year for each of the country's 53 million people. Decades of civil war against ethnic militias in eastern Myanmar have worsened the situation; A study by the Thailand-based Backpack Health Worker Team showed the region's 500,000 internal refugees have malaria infection rates as high as 12 percent. "So far, the malaria parasite has started to develop resistance to all drugs apart from those in the artemisinin family," said Francois Nosten, a French malaria expert in the northwestern Thai border town of Mae Sot. "If this starts to happen, there is cause for real concern." One drug-resistant strain born in southeast Asia has already made it to Africa, Nosten said. If an artemisinin-resistant variety reached the continent, the effects would be devastating. "If we find evidence that it has changed to become resistant to artemisinin, we would have to contain it here -- but how you would do that, I just don't know," said Nosten, director of the Shoklo Malaria Research Unit, a field station attached to Bangkok's Mahidol University.

TB MAKES COMEBACK While Nosten said there were no signs yet of malaria becoming immune to ACTs in the jungle-clad border region, the same cannot be said of tuberculosis, a disease that -- as with malaria -- had been on the retreat in Thailand. Mae Sot general hospital, a sprawling complex overflowing with Burmese and Thai patients, has admitted 105 Thai and 38 Myanmar TB patients so far this year compared to 102 and 79 in the whole of 2006. More worrying still, five cases were "multi-drug resistant," meaning patients have to undergo an expensive and arduous two-year course of pills and injections. Even then, there is only a 50 percent chance of survival. Aid agency Medecins Sans Frontieres (MSF) (Doctors Without Borders), which is treating 15 "multi-drug resistant" Myanmar patients in a refugee camp in Thailand, is acutely aware of the problems of treating TB patients in fluid populations. Treatment normally lasts six months, but many patients feel better after half way through and so stop taking the pills. "There needs to be a huge push in TB education, in telling people the extreme importance of taking the treatment properly and not stopping as soon as you start to feel better," MSF Mae Sot's field coordinator Andres Romero said. "But with migrants, how do you follow up to ensure they have not become a defaulter? They've no mobile, no land-line phone, no address." STRUGGLING Although wealthy and advanced by regional standards, Thailand's public health system in Mae Sot is struggling under the weight of dealing with an estimated 150,000 migrants from Myanmar -- and the diseases they bring with them. Apart from a one-off payment from the Global Fund to treat TB in migrants, Mae Sot hospital gets no extra government cash for the thousands of Burmese flooding across the highly porous border, drawn by the prospect of free health care. All the signs are of a hospital struggling to cope. Its open-air corridors are choked with beds and patients hooked up to drips beneath whirring ceiling fans. Relatives of the sick, who range from land-mine amputees to TB patients on respirators, lie curled up on reed mats beneath many of the beds. "We treat every patient who comes here, Burmese or Thai, exactly the same. Not to do so would be completely unethical," director Kanoknart Pisultakoon said. "Often the Burmese have tried to treat themselves and it hasn't worked so when they come to hospital they are very sick. Then, when they get better, they go back to Myanmar and tell their friends. "The word spreads and every year, there are more migrants, more patients and more serious diseases," Kanoknart said. "It makes me worry for the future -- how we can control the migrants."

Burma Must Tackle TB and HIV by Interpress Service, September 5, 2005

BANGKOK, Sep 5 (IPS) - For over 15 years a clinic in Mae Sot, a town along Thailand's northwestern border, has offered a glimpse into how widespread tuberculosis (TB) is in neighboring Burma. It is to that clinic, run by Dr.Cynthia Maung, that a stream of poor men, women and children, escaping military-ruled Burma for Thailand, come to for a health check. "In 2004 we detected 700 cases of TB, of which 250 needed treatment," said Maung, herself a refugee who fled Burma in 1988 following Rangoon's harsh crackdown on a pro-democracy movement. TB remains one of the major diseases that the hundreds crossing over from Burma suffer from, she explained during a telephone interview from her clinic in Mae Sot. "We are concerned because every year the cases are high". Similar conclusions have been reached by officials at Thailand's ministry of public health, given the number of TB cases that have been detected during mandatory health tests done to the thousands of migrants from Burma who seek legal employment in this country. In 2003, for instance, there were 1,766 Burmese with TB who required follow-up treatment, states a health ministry study. The infection that followed TB was syphilis, with 952 cases. In 2002, in the Tak province alone, where Mae Sot is located, Thai health officials had required 885 Burmese to commence medical treatment for TB. That was out of an estimated 30,000 migrant workers who were seeking jobs in the large agriculture farms and the many garment factories there. The number of migrant workers with TB has added to the incidence rate of this killer disease in Thailand, compelling Bangkok to step up TB detection and treatment efforts. "This year we put TB among one of the priority problems we have to tackle," Dr. Kamnuan Ungchasuk, director of the bureau of epidemiology at the health ministry, told IPS. These numbers, however, are dwarfed by reports that Burma has 97,000 new cases of TB ever year and this South-east Asian nation is classified by the World Health Organization (WHO) as being among the world's 22 'high burden' countries with the disease. More troubling for public health experts is the high prevalence of multi-drug resistant TB (MDRTB) in Burma. It has four percent new cases of MDRTB, states the Geneva-based health body. The frequency of MDRTB, which is incurable since it does not respond to available cheap antiTB drugs, has placed Burma on the top of the list of afflicted countries in the region. According to the WHO, Thailand has 0.9 percent of the new cases of MDRTB, Bangladesh has 1.4 percent new cases and even India, the country with the greatest TB burden, there are only 3.4 percent new MDRTB cases annually. The only country in East Asia worse off than Burma for new MDRTB cases is China, with a reported 5.3 percent prevalence rate. "The situation in Myanmar is a concern because four percent new cases in a high burden country is no trivial number of patients - several thousands, likely between 4,000-6,000 cases," a WHO official told IPS.

Such revelations about Burma, whose military rulers changed the country's name to Myanmar, come at a time when there is a global effort to rid the world of this pandemic, which kills nearly two million men, women and children every year. As part of the Millennium Development Goals (MDGs), world leaders pledged at a U.N. summit in New York in 2000 to stop the spread of the world's leading killer diseases - AIDS, TB and malaria - by 2015. Other MDGs to be achieved by that year include halving the number of those living on less than one US dollar a day, ensuring universal primary education for all boys and girls, reducing by two-thirds the number of children who die before reaching five years of age and reducing by three-fourths the number of women who die while giving birth. And the WHO makes the alarming prediction of what the world will be faced with if TB, a curable infectious disease, is not overcome. In the next 20 years, almost one billion people will become newly infected, 200 million people will develop the disease and 35 million will die from it, it states. It is a scenario made worse by the ease with which TB feeds off the other global pandemic, AIDS, which killed 3.1 million people last year. "TB is the leading killer of people infected with HIV," states the WHO, due to the weak immune systems of those with the virus that causes AIDS. Currently, some 14 million people are co-infected with TB and HIV, of which 70 percent are in Africa. The likelihood of Burma adding to those numbers has grown in the light of the fact that the country has the second highest prevalence rate of HIV in South-east Asia with an estimated 170,000 to 620,000 people living with the killer disease, according to a U.N. agency. And a decision by an international funding agency to pull out of Burma in August due to roadblocks imposed by the military regime -- consequently hampering its 98.4 million-dollar contributions for programs to combat AIDS, TB and malaria - has set off more alarm bells. Yet, the WHO feels that such concern, at least over TB, may be misplaced, since the junta has implemented a range of public health initiatives despite its limited resources and a weak health system. "For a resource-constrained country, Myanmar has a well functioning TB program and a very good laboratory, which should enable the country to address the problem of MDRTB," says the WHO official. "Political commitment to DOTS is high in Myanmar," added the official, referring to the Directly Observed Treatment Short Course strategy of diagnosing and ensuring administration of cheap anti-TB drugs to patients. "DOTS coverage is 100 percent, meaning that all of the 324 townships have a DOTS clinic, although access to services varies widely".