Indian J Med Res 128, July 2008, pp 1-3

Editorial

Malaria in the South-East Asia Region: Myth & the reality

Malaria continues to remain a major public health Region is home to the two predominant types of malaria,
problem worldwide. Much emphasis in the past has been caused by Plasmodium vivax and P. falciparum. P.
on sub-Saharan Africa due to its heavy burden. falciparum that often causes cerebral malaria and other
However, concerned with the persisting situation of life-threatening conditions, is showing a disturbing
malaria in Africa as well as other regions, the 60th World increasing trend accounting for 50 per cent of all malaria
Health Assembly passed a resolution in 2007 calling cases8. The disease is unstable, with outbreaks occurring
for intensified prevention and control efforts globally, frequently, affecting all age groups and taking a heavy
and elimination of malaria in areas where this was toll of life every year, thereby seriously threatening
feasible and sustainable 1. Parasite resistance to public health.
antimalarials, rapidly changing human lifestyles, as well The malaria situation in the Region remains highly
as ecological and environmental changes have also dynamic and evolving, and likely to be further
helped focus on a disease long neglected by the aggravated by climate change. There is an evidence to
international community. show that warming of the earth’s temperature and
The Roll Back Malaria (RBM) programme of the increasing precipitation will hasten maturation of the
World Health Organization (WHO) in 1998 focused parasite in mosquitoes, increase the biting frequency
firmly on Africa2 for several years until 2006, when the and create conditions more conducive to mosquito
new WHO Global Malaria Programme (GMP) was breeding9. Climate change is expected to worsen in the
launched3. The focus on Africa was understandable due future, both in frequency and intensity, as also the health
to the burden it suffers; nearly 90 per cent of the consequences. This will disproportionately affect the
estimated one million preventable malaria deaths occur poor and marginalized sections of society, particularly
in Africa4. It is however a myth that malaria is a problem those living in remote forest areas such as tribal
of Africa only. Clearly, malaria and other vector-borne populations. In India, for example, 65 per cent of all
diseases pose a huge problem in Asia, particularly the malaria cases are reported from six States - Orissa,
11 member countries of the South-East Asia (SEA) Jharkhand, Chhatisgarh, Madhya Pradesh, West Bengal
Region and deserve due attention both at the national and the States in the North-East. In some of these areas
and international levels. such as Orissa, the situation of malaria is even worse
than in sub-Saharan Africa. Malaria is also a severe
The disease burden in the South-East Asia Region: problem among hill tribes of northern Thailand and
the reality Myanmar.
Malaria is an enormous health and developmental Compounding the problem, resistance to anti-
problem in the SEA Region as a staggering 687 million malarials is emerging faster in Southeast Asia than in
people are at high risk for malaria, with an estimated any other part of the world. Over the past three years,
90-160 million infections and more than 120, 000 deaths dangerous levels of treatment failure to even newer
occurring each year5. The social, cultural and economic drugs such as artemisinin-based combination therapy
dimensions in terms of disproportionate impact on the (ACT) have been reported from the Thailand-Cambodia
poor, the associated loss of wages and productivity both border10, with great potential to spread across borders,
at the micro- and macro-levels are enormous6,7. The SEA thereby compromising international health security.
1
2 INDIAN J MED RES, JULY 2008

This site is historically notorious since resistance to Third, from the malaria programme perspective,
chloroquine, sulphadoxine/pyrimethamine and what is needed is an impetus and a sense of urgency to
mefloquine originated and spread from there11,12. Due put malaria in the SEA Region high on the national and
to widespread and high levels of resistance, chloroquine international health and development agenda.
and sulphadoxine/pyrimethamine are presently of no Programme development and management must be
use in most countries. strengthened at the national level and methods for the
collection and quality of surveillance data improved in
Malaria has a severe and often disastrous economic
order to obtain clarity on the disease burden. A system
impact on households in poor communities, which
must be set up for tracking progress with the help of a
traditionally face the major brunt of the disease. In the
few critical indicators and the data generated used to
absence of savings, the poor are compelled to either
guide action.
borrow or sell assets such as livestock and farmland to
cope with the illness and its complications. The socio- Fourth, after decades of neglect, there are now
economic dimensions of malaria, besides its health greater possibilities for collaboration and partnerships
impact, call for priority to be urgently accorded to both at the national and international levels. Over the
enhancing access to health services in malaria- past four to five years, the global commitment has
vulnerable areas, with equity as the underlying theme. increased, as reflected by initiatives such as the Global
Fund to fight AIDS, TB and malaria (GFATM), World
The need for a paradigm shift
Bank, European Union, USAID, the Bill and Melinda
There is a need for a paradigm shift in our approach Gates Foundation, and Centers for Disease Prevention
to malaria for the following reasons: and Control (CDC)18. Some of these initiatives, in
particular GFATM, World Bank and USAID, have
First, the evidence, both historical and at present,
provided support to countries in the SEA Region,
shows that malaria can be controlled or even eliminated.
encouraged by the fact that investment in malaria control
The national malaria eradication programme, which was
can return handsome dividends in the long run19 As a
started in India in the 1950s, led to a drastic reduction
result, enormous and unprecedented opportunities are
in the number of malaria cases over two decades13. In
1970, only a few thousand cases were detected in India now available, which should be used to substantially
but soon thereafter, malaria resurged as a result of scale up interventions against malaria and other vector-
borne diseases, and build health systems to ensure
complacency and inadequate administrative support14.
In 1977, under the modified plan of operations, the sustainability.
programme approach had to be shifted from malaria The price of neglect
eradication to control, with priority given to reducing
The situation calls for action that must go beyond
the number of deaths15.
“business as usual”. Otherwise, unnecessary and
Past efforts (such as the enormous reduction in preventable deaths, and suffering of the poor and
burden during the 1950s and 1960s)15 and recent success vulnerable due to malaria will continue. Poorly
stories in Betul, Karnataka16 and Gujarat17 show what performing national malaria programmes will also
can be achieved if such examples are replicated. At the seriously undermine countries’ and the Region’s ability
same time, Sri Lanka and Thailand have demonstrated to achieve the Millennium Development Goals (MDGs).
an enormous reduction in malaria morbidity and
WHO accords malaria a very high priority and has
mortality due to concerted efforts; in particular, effective
been assisting Member countries in mobilizing
treatment policy, increased access to treatment facilities
resources particularly from the Global Fund. In 2006,
and innovative approaches to vector control involving
the WHO Regional Office for South-East Asia published
the community.
a revised strategy for malaria control5 which was also
Second, we have at present even better and more an agenda item for discussion at the WHO/SEARO
effective tools to control malaria, such as long-lasting Regional Committee (RC) in Thimphu, Bhutan in
insecticidal nets (LLIN), a rapid diagnostic test (RDT) September 2007. The RC has recommended that all
and ACT. However, the availability of these must be member countries fully implement the revised strategy.
scaled up substantially in order to make an The strategy stresses on the need to focus on local
epidemiological impact in terms of reduction in specific measures based on ecological, environmental
morbidity and mortality. and behavioural determinants prevalent in the area, and
 NARAIN: MALARIA IN THE SOUTH-EAST ASIA REGION 3

on the inter-sectoral response to malaria, with full 5. www.searo.who.int/en/, accessed on 6 May 2008.
engagement of government ministries, NGOs, civil 6. World Health Report, 2004, Report of the Director General.
society and the private sector. Since much of malaria Geneva: WHO, 2004.
follows developmental activities, it should be part of 7. Khanum S, Singh A. Health, poverty and Human Security:
healthy public policies mandating that before any Illustrations from Malaria Control Programmes in the SEA
developmental work is initiated, the public health Region. Regional Health Forum WHO SEAR 2007; 11 : 33-
44.
consequences must be assessed and appropriate steps
taken to safeguard these. Finally, given the 8. The work of WHO in the South-East Asia Region: report of
the Regional Director, 1 July 2007-30 June 2008. New Delhi:
epidemiological situation in the Region, with huge World Health Organization Regional Office for South-East
morbidity and relatively fewer deaths, a balance must Asia; 2008.
be struck between prevention and treatment 9. Andrew K Githeko, Stene W bindry, Ulisses E Confalonieri,
interventions. Jonathan A Patz. Climate change and vector-borne diseases :
a regional analysis. Bull World Health Organ 2000; 78 : 1136-
In conclusion, malaria is clearly a huge problem in 47.
the SEA Region, requiring an urgent attention from the
10. WHO/SEARO. Containment of malaria multi-drug resistance
policy-makers at the national level as well as of the on the Cambodia-Thailand border. Report of an informal
international community. Great opportunities are consultation. Phnom Penh, 29-30 January 2007.
available at present to not only control and eventually 11. Wongsrichanalai C, Webster HK, Wimonwattrawatee T,
eliminate malaria but also to strengthen health systems Sookto P, Chuanak N, Thimasarn K, et al. Emergence of
and augment efforts to contain other vector-borne multidrug-resistant Plasmodium falciparum in Thailand: in
diseases. A paradigm shift in our approach from both vitro tracking. Am J Trop Med Hyg 1992; 47 : 112-6.
the policy and programme point of view is required for 12. Thimasarn K, Sirichaisinthop J, Vijaykadga S, Tansophalaks
the containment and elimination of malaria from the S, Yamokgul P, Laomiphol A, et al. In vivo study of the
response of Plasmodium falciparum to standard mefloquine/
SEA Region. sulfadoxine/pyrimethamine (MSP) treatment among gem
Jai P. Narain miners returning from Cambodia. Southeast Asian J Trop Med
Public Health 1995; 26 : 204-12.
Department of Communicable Diseases
World Health Organization 13. http://www.malariasite.com/malaria/history_india.htm.
Regional Office for South-East Asia 14. http://whoindia.org/cds/CD/RBM/roll_backmalaria.htm.
Indraprastha Estate, Mahatma Gandhi Marg 15. http://india.gov.in/sectors/health_family/vector_borne.php,
New Delhi 110 002, India accessed on May 6, 2008.
[email protected] 16. Singh N, Shukla MM, Mishra AK, Singh MP, Paliwal JC,
Dash AP. Malaria control using indoor residual spraying and
References larvivorous fish: a case study in Betul, central India. Trop Med
1. www.who.int/gb/ebwha/pdf_files/wha60, accessed on May 4, Int Health 2006; 11 : 1512-20.
2008. 17. Ghosh SK, Dash AP. Larvivorous fish against malaria vectors:
2. United Nations. Resolution of the Sixtieth Session adopted a new outlook. Trans R Soc Trop Med Hyg 2007; 101 :
by the General Assembly: 2001-2010: decade to roll back 1063-4.
malaria in developing countries, particularly in Africa. New 18. Breman JG, Alilio MS, Mills A. Conquering the intolerable
York: United Nations; 2000. burden of malaria: what’s new, what’s needed: a summary.
3. http://www.who.int/malaria/, accessed on May 6, 2008. Am J Trop Med Hyg 2007; 71 (Suppl 2) : 1-15.
4. Breman JG. The ears of hippopotamus: manifestations, 19. Kumar A, Valecha N, Jain T, Dash AP. Burden of malaria in
determinants and estimation of malaria burden. Am J Trop India: retrospective and prospective view. Am J Trop Med Hyg
Med Hyg 2001; 64 : (Suppl 1) : 1-11. 2007; 77 (Suppl 6) : 69-78.