This article was first published by MSF-Australia for their Doctors for Doctors Day.
I'm working in Myanmar (the former Burma), on a malaria control project in an area called the Mon state in Lower Burma. The Mon state is mostly inhabited by a minority ethnic group called - strangely enough - the Mon. But there is also many Karen (or Kayin) people, another minority ethnic group. These people are a little better known than the Mon, because of the displaced person camps across the border in Thailand, where MSF has worked and also published a lot of research on malaria. Down here in Lower Burma there's a ton of rain compared with Middle or Upper Burma, so consequently, a ton of malaria comes once the rains hit.
The rains hit about a month ago, our logistician's roof blew off in a storm last weekend (I'm now concerned about our roof, as he played a part in building it!), our field co-ordinator got Dengue and had to be evacuated to Rangoon - and our malaria rates have shot up more than 30-fold.
The Thai-Myanmar border area has the rather dubious honour of having the most drug resistant falciparum malaria in the world. Here our treatment guidelines are based on the research from the Thai border camps, and use the artemisin derivatives. After some work by MSF lobbying and educating, the government also changed their guidelines earlier this year in line with ours. Only problem is though, Myanmar has the second worst public health system in the world according to the WHO (Sierra Leone is ranked last), and there is no government supply of artemisin derivatives available. But the first step has been taken.
MSF uses mobile clinics to visit villages for malaria treatment and prevention. Here a national staf member is taking a bloodsample from a child. The medical team usually exists out of five to seven people; a patient tracer who goes into the villages to trace sick people, a doctor for a general medical check up, a nurse and three lab technicians to perform the malaria test. During the dry season MSF uses trucks to travel through the country. In the rainy season (June-October), it is impossible to travel over land so MSF often uses boats to reach the remote villages.
The artemisin derivatives (we use IV Arthemeter and oral Artesunate) are the only drugs available at the moment where there is no recorded resistance in falciparum malaria. Therefore they need to be used with great care. Although Artesunate will kill the P.falciparum parasite by itself, it is given whenever possible with Mefloquine, despite the high rate of side effects of the latter drug.
This reduces the chance of resistance to Artesunate forming, and reduces the number of doses of Artesunate required from seven to only three, thereby increasing compliance. A large part of our role in not only treating malaria, but preventing the emergence of resistance, is making sure the patients take all their doses of Artesunate.
This means that each individual patient needs to attend one of the nine microscopy units on the second day for medication, and if they do not attend, then it is MSF's responsibility to locate them and give the second dose. This takes a lot of time, and uses a lot of resources. The telephone system is not reliable; the use of two way radios is forbidden; and we are unable to import any four-wheel drives; so our vintage 1970's vehicles we use for follow up are expensive to maintain.
The people of Myanmar are amongst the poorest in the world, and malaria is the cause of more mortality and morbidity than any other disease. MSF's goal is to make high quality treatment of malaria widely available, for no cost to the patient, and ensure the correct usage of these medications and in so doing, prevent the disaster of resistance to the artemisin derivatives. Hence, the doctors should give us their money. So with diligence and luck on our side, we can protect the Artemisin derivatives, our last big gun in the fight against the fiendish Plasmodium falciparum.