The Asean
Economic Community (AEC), a huge common market of $2.6 trillion and more than
622 million people, is not without its disparities. The AEC with 10 Asean
countries is a hodgepodge of least developed, developing and developed nations
all vying for a common market with a free-flow of goods, services and labor.
As
Cambodia aspires to graduate soon from the list of least developed countries
with a stable GDP growth of seven percent a year, it hopes to attract more
foreign direct investment from its rich Asean neighbors through the AEC.
In the
meantime, however, the Kingdom has to grapple with a large outflow of mostly
male unskilled labor moving across common borders to work in Thailand, Malaysia
and Singapore and also in Vietnam-owned logging companies operating at the
Cambodia-Laos and Cambodia-Vietnam borders.
As travel
becomes easier the number of migrant workers moving across borders in the
region also expands, further increasing the risk of the spread of multi drug-resistant
malaria which is endemic in Asean member countries in the Greater Mekong
Sub-Region (GMS), namely Cambodia, Thailand, Laos, Vietnam and Myanmar,
formerly known as Burma.
Of the
four species of malaria parasites transmitted by mosquitoes, Plasmodium
Falciparum carried by mosquitoes in the Anopheline family is the most dangerous
and accounts for more than 50 percent of cases and most deaths in the GMS.
The World
Health Organization (WHO) is worried
that falciparum malaria could become untreatable with currently available drugs
within a few years. Artemisinin combination therapies, or ACTs, are the most
effective treatments for this deadly form of malaria, but the WHO is
documenting fast-growing resistance against these antimalarial medicines in the
GMS.
To date,
resistance to artemisinin-derived antimalarials have been confirmed in Vietnam,
Laos and Myanmar since resistance was first detected along the
Cambodia-Thailand border in Pailin in 2004. The presence of mutations linked to
delayed parasite clearance seems to be either spreading or popping up
independently in the GMS.
The Asean
Economic Community will see both legal and illegal migration, of young adult
males who are generally poor, to the neighboring rich Asean countries as it is
the poorest who cannot earn enough to support their families in their countries
of origin. It will be workers moving across borders from countries with high
malaria prevalence to countries with zero or low malaria cases.
What is
alarming is the movement of asymptomatic carriers of malaria, those carrying
low levels of the parasite in their body – enough to infect mosquitoes to
spread the disease – but not showing any signs of sickness.
People
develop an acquired immunity to malaria in areas where there is a high
incidence of the mosquito-borne disease and they are walking time bombs, not
showing symptoms and spreading the disease widely.
Cambodia’s
National Malaria Centre (CNM) has documented asymptomatic cases in Pailin,
Battambang, Oddar Meanchey and Stung Treng provinces – all former Khmer Rouge
strongholds where Chinese-supplied artemisinin monotherapies, not combined with
a partner drug, were used indiscriminately to treat all forms of malaria. That
malaria parasites in Cambodia were already resistant to artemisinin in the late
1970s and 1980s, would come as no surprise.
Border
screening of mobile migrants by health officers at immigration checkpoints is a
good way to detect malaria infections and prevent the disease from spreading.
But realities need to be taken into account.
While
many official border crossings and check-points are available at Asean’s
contiguous borders, they, however, are only popular among tourists, traders and
frontier workers. The majority of cross-border migrants use the natural border
crossing points, walking across the mountains or wading across narrow rivers
that divide the nation’s borders.
Despite
the development of legal migration channels, they are currently not affordable
or accessible to most migrants. So migrants continue to cross the borders
illegally to work as undocumented workers in the host country. This makes it
difficult to measure the actual migration volume.
For
instance, after the harvest season in Cambodia, many farmers in Stung Treng
province would cross the border illegally into Laos to work as part-time
loggers for companies making high-end rosewood furniture. Rosewood can fetch
thousands of dollars per cubic meter and loggers can earn hundreds of dollars
working for Vietnam-owned companies making luxury wood furniture.
Between
2000 and 2010, Laos significantly reduced its malaria burden and was on track
to achieve the World Health Assembly target of cutting the malaria burden by 75
percent by 2015. However, in late 2011, according to the WHO, malaria outbreaks
began to flare up again, mostly in Laos’ southern provinces bordering Cambodia.
Little
knowledge, less awareness and self-treatment with counterfeit or sub-standard
drugs purchased over the counter are important factors that need to be
addressed, by both the WHO and national malaria programs, coupled with
international funding for cross-border active disease surveillance, if progress
is to be made in containing the spread of artemisinin resistance and
eliminating malaria in Asean and the GMS.
The
movement of infected people from areas where malaria is still endemic to areas
where the disease had been eliminated can lead to a regional resurgence of the
disease.
Sonny
Inbaraj Krishnan studied in the Liverpool School of Tropical Medicine in the UK
and worked on malaria in Cambodia for the World Health Organization from 2010
to 2014. The views in this opinion piece are his own.
Sonny
Inbaraj Krishnan
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