This weeks letter home : Médecins Sans Frontières Australia

FROM Myanmar (Burma) Ingrid Hopper

Ingrid Hopper is a medical doctor who has just returned from Myanmar. She was there for six months, from March to September 2003. This has been her first mission with Médecins Sans Frontières. Ingrid is from Melbourne. This is a letter she wrote during her time in Myanmar.

I’m working on a malaria control project in an area called the Mon state, which is mostly inhabited by a minority ethnic group called the Mon, in Lower Burma. There are also many Karen (or Kayin) people, another minority ethnic group, in this region. Médecins Sans Frontières has been doing a lot of malaria work with the Karen people in displaced persons camps over the border in Thailand.

Lower Burma's high rainfall rate heralds an increase in instances of malaria.
© Marco van Hal

Lower Burma gets a lot of rain, much more than Middle or Upper Burma. This heralds an increase in instances of malaria. The latest rains hit about a month ago and malaria rates have shot up more than thirty-fold. And to top things off our field coordinator got Dengue Fever and had to be evacuated to Rangoon.

The Thai-Myanmar border area has the rather dubious honour of having the most drug-resistant falciparum malaria in the world.

This has been attributed to the unregulated use of anti-malarials, so-called “presumptive treatment”. In addition, population migrations and decreased health infrastructure are contributing factors to this alarming statistic.

Our treatment guidelines have been adapted to capture the research carried out in the Thai border camps. We are using artemisinine derivatives in our treatments. The health authorities of Myanmar changed their guidelines earlier this year to bring them in line with ours which was a very positive move. The only problem is that the public health system in Myanmar does not have the funds to supply this drug! But the first step has been taken.

Reducing resistance
Artemisinine 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 to avoid, or at least forestall, the development of resistance.

On the way o the MSF clinic
© Marco van Hal

Artesunate has the capacity to kill the falciparum parasite by itself, but to do this it needs to be given daily for seven days. Getting a patient to comply with seven days of treatment is difficult even in highly educated countries like Australia. In a poor country, with low levels of education, it is near impossible, because once patients feel well they tend to hoard the drug until the next episode of fever.

So the concept of dual therapy, as used in the treatment of HIV, leprosy and cancer, has been applied to malaria.

Artesunate is given whenever possible with mefloquine, despite the high rate of side-effects of the latter drug. The rationale is that the chance of a single malaria parasite developing resistance to both drugs at the same time is low enough to be negligible. Therefore if a parasite is not knocked out by one drug, it will be knocked out by the other.

It is believed that with dual therapy the development of resistance in the new drug artesunate is delayed, and in some areas it has been shown to even reduce the levels of resistance in mefloquine.

Ensuring compliance
The practical benefit of dual therapy is that it reduces the number of doses of artesunate required from seven to only three, which has a positive impact on patient compliance. It’s important that the patient is observed taking the first two doses of medication, so we know they have not vomited or hoarded. The first dose is given either at the mobile clinics we run, or at one of eight units in rural areas set up by Médecins Sans Frontières for the diagnosis and treatment of malaria.

If the patient does not attend the mobile clinic for their second dose of medication, then they need to be found. This takes a lot of time, and uses a lot of resources. The telephone system is unreliable and hardly anyone has a telephone. The use of two-way radios is forbidden. In addition we are unable to import any four-wheel drives so the vintage 1970s 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. Médecins Sans Frontières’s goal is to make high-quality treatment of malaria widely available, at no cost to the patient, and to ensure the correct use of these medications. In so doing, it is hoped that we can help prevent the disaster of resistance to the artemisinine derivatives.

So with diligence, luck on our side and some support from outside we can protect the artemisinine derivatives, our last big gun in the fight against malaria.

August 2003

Extending care for malaria and AIDS patients

Malaria is the leading cause of illness and death in the country, and local strains of the disease are highly resistant to common treatments. For this reason, in 1996, MSF started giving malaria patients highly effective artemisinin-based combination therapy (ACT). This new therapy cures more patients than older treatments and there is no known resistance to it.

Providing care for those living with HIV/AIDS is another large part of MSF's medical activities in Myanmar. MSF started the country's first program using life-extending antiretroviral (ARV) treatment in Feb 2003.

Assisting isolated civilians: In Rakhine state, the Muslim majority (known as the Rohingyas) continues to be persecuted by the authorities and is denied basic civil rights and liberties, most notably the right to move, leaving them essentially trapped within their own villages. MSF aids these civilians by providing primary health care and specifically, treatment for malaria, a common disease in the area. By August 2004, an estimated 35,000 people had received medical assistance... » More

COUNTRY PROFILE Myanmar [Burma]
Population: 48,956,000
Life expectancy:56 years
Expatriate staff: 48 | National staff: 669
MSF has worked in Myanmar since 1992.

Myanmar map

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