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Although malaria is decreasing in Myanmar, resistance to anti-malarials is on the rise in the region and the focus is now to treat people early, particularly in remote communities. MOCRU has set up a network of community health workers, trained and supplied with diagnostics, bednets and treatments, to help improve access to healthcare as well as produce the evidence to encourage policy changes.

My name is Frank Smithuis, I’m a medical doctor and the director of MOCRU, Myanmar Oxford Clinical Research Unit. We focus mainly on infectious diseases and access to health care in the most remote communities.

The main problem for malaria in Southeast Asia, and therefore also in Myanmar, is falciparum malaria because it is the biggest killer. I estimate very roughly, because there’s not a lot of data available, yearly incidents of 5 to10 millions. However, that has gone down substantially and I don’t know what it is at this moment but I expect it to be maybe 100,000, 200,000 or 300,000 cases a year.

There is of course the problem of resistance: the medicines that are used to treat malaria in this region are gradually not effective any more, and the parasite is becoming more and more resistant. This is particularly a problem in Cambodia, Thailand and Vietnam. Actually in Myanmar artemisinin is still effective, resistance is limited, and the artemisinin combination treatment is still effective. In practice, we focus on treating people early in the community. If you treat people early then they can’t transmit malaria and that is very important.

MOCRU and Medical Action Myanmar, an NGO I am working with, focus on working in the most remote communities. That is where malaria is, and there are no health care activities there. We have trained community health workers, villagers, and we trained them how to used rapid tests for malaria, and then gave them enough treatment. We provide medicines, mosquito nets, tests, but also very importantly we keep on training them. When I studied medicine and I saw my first patient, I didn’t know what to do – I learnt a lot but I didn’t know how to manage a patient, and it was a senior doctor that helped me and guided me along. It’s the same for community health workers: we can train them but at a certain moment they need to see patients together with a senior person. That is what we do: we send a team every month to all of these remote communities, and they see patients together. That programme has been very successful; malaria has decreased on average in the communities that we work with by 70% per year, and that has gone on for 6 to 7 years now.

We have to prove to the world, to the ministry of health, to other players, what works and what doesn’t work, I think that’s very important. I can be convinced of something but if I don’t have proof then it’s very difficult to ask other people to implement the same. That’s why when we do activities we measure the results, we compare it with when we do not do these activities. Then we have something in hand, and with these results we go to the government, we go to the ministry of health and we show the results. That has lead several times to a change to treatment protocol so that’s basically it – we do research and we try to change policy. It is very much related to direct service delivery to the people.

There is not so much malaria anymore, so people say ‘so why focus on malaria?’ well if you want to eliminate it, you have to eliminate the last parasite; that’s actually very difficult. You can see with polio, there is very little polio in the world, but when you drop your activities to contain polio and to eliminate polio, polio will come back. It’s the same with malaria – if we stop now or if we stop in the next few years, malaria will come back, and then it was all for nothing.

Frank Smithuis

Professor Frank Smithuis is the director of MOCRU, our Myanmar Oxford Clinical Research Unit. MOCRU involves a network of 6 clinics and 650 community health workers in remote areas.
Most research questions originate from the day to day health issues in this network. Research interests include the epidemiology and management of malaria, and the management of tuberculosis, HIV and opportunistic infections.

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