As the post-coup conflict undermines health services and displaces entire communities, malaria is making a dramatic comeback in Kayin and Kayah states, wiping out years of progress.
Since giving up his hotel bar job in Yangon shortly after the 2021 coup to join the fight against the junta in Kayin State, Ko Phoe Kar* has almost died twice in the jungle – not from bullets or landmines but from malaria.
Phoe Kar, leader of the Yangon Special Team resistance group, says all of the more than 30 fighters under his command have been sick with the mosquito-borne disease, which is seeing a dramatic resurgence along the border with Thailand.
The first fighters started coming down with severe fevers in June last year, at the onset of the rainy season. They all moved to a village hospital in Hpapun Township run by the Karen National Union, the oldest ethnic armed organisation in Myanmar, which has closely aligned itself with the post-coup uprising.
“We got sick from a lack of medicine and clothing. We were in a lot of trouble in the forest,” Phoe Kar told Frontier. “It rained heavily, making it impossible to travel. The roads were destroyed, impassable for vehicles, and it’s very difficult to get medicine.”
Local ethnic healthcare groups said the military has been blocking medicine and pharmaceuticals from reaching Kayin and Kayah states, while also restricting general travel along major roads.
Medical experts say cases of malaria are surging, especially during the rainy season from June to October, because of mass movements of people fleeing conflict and a general breakdown of health services.
“Before the coup, malaria cases were pretty much under control. But since then rates have been spiking along the Thai-Myanmar border,” said Saw Ba Win, director of the Ethnic Health Systems Strengthening Group, a network of ethnic and community-based health organisations working in eastern Myanmar.
A dramatic resurgence
According to the Burma Medical Association, an organisation that has provided health services in conflict areas for over two decades, Kayin State saw a total of 8,707 malaria cases in 2020, rising to 15,848 in 2021 and 36,691 cases in 2022.
“The downward trend has been quickly reversing since 2021 after the armed conflict and population displacement in Kayin State,” BMA director Saw Nay Htoo told Frontier.
In the first six months of this year – before the onset of the mosquito-breeding rains – the BMA recorded 20,547 cases, and predicted there will be over 50,000 cases by the end of the year.
Even the junta’s numbers show a dramatic leap. Its health ministry reported in July last year that the number of malaria cases nationwide rose to 79,001 in 2021, up from 58,835 the year before. No figures have been released for last year, and it’s not clear how the regime collates data across large rural areas of the country it does not control.
The health ministry of the National Unity Government, the parallel administration appointed by elected parliamentarians ousted in the coup, has not released any data on malaria.
The KNU’s Karen Department of Health and Welfare said malaria was not among the 10 most common diseases recorded in Kayin before the coup but it now ranks seventh. “We find one in three sick patients tested with rapid test kits have been infected with malaria,” KDHW head Saw Diamond Khin said.
The Mae Tao Clinic, founded in the Thai border town of Mae Sot by Dr Cynthia Maung in 1989 for refugees from Myanmar, treated just 18 patients for malaria in 2021 but last year cases jumped to about 300. In the first half of this year the clinic has already seen some 150 patients.
“Most of the patients who come to the clinic are migrant workers and displaced people from the Myanmar side. In Thailand, there is no malaria infection in urban areas, only at the borders. The rate of malaria is only one percent [in Mae Sot],” she added.
Accurate figures are harder to find in Kayah State. A healthcare worker with the Civil Health and Development Network, a local NGO, said Kayah was also seeing a rise in cases, but they could only assess numbers accurately where there was access to health care.
“Malaria is in nearly every township. The current number of malaria cases on the ground may be much higher than those recorded,” he said.
Difficult accessing care
In Kayah, the United Nations estimates that nearly 100,000 people have been displaced by the conflict, around one third of the state’s population according to the 2014 census.
The coup has also precipitated a healthcare crisis, both because of widespread fighting and a large-scale strike of civil servants refusing to work for the military regime.
“Treating malaria has become much more difficult. We don’t have enough medicines at hand. Anti-malaria drugs are in short supply and can’t be delivered to areas where the disease is endemic,” said Dr Than Tun*. The surgeon quit his job in Kayah’s capital Loikaw to join the Civil Disobedience Movement in protest of the coup, and now works with the local NGO Loyalty Mobile Team for Karenni.
His mobile team provides healthcare to around 30,000 residents in 26 camps for internally displaced persons in Kayah’s Demoso Township and another four camps along the border of Hpruso and Bawlakhe townships. But others can’t be reached.
“Because of heavy fighting, ethnic IDPs fleeing the war cannot get to clinics,” he added.
Diamond Khin, from the KNU’s healthcare department, said it’s a similar story in Kayin, where he expects malaria cases to rise as more people are displaced by conflict.
“If migration causes more malaria, then we won’t have enough medicine. It will be a challenge. Also, it’s not easy to get around in the state, so transporting goods and medicine is a big problem,” he told Frontier.
Cases are also on the rise because of the onset of the monsoon rains, when the mosquito population increases, explained Dr François Nosten, professor of tropical medicine and director of the Mae Sot-based Shoklo Malaria Research Unit, an organisation founded in 1986 that provides health care to marginalised populations on both sides of the border.
Nosten said SMRU has had difficulty in delivering necessary supplies to villages inside Myanmar and accessing the medicine tafenoquine, used to prevent and treat P. vivax malaria.
“Although it is registered in the USA, Australia and Canada, it is not available in Thailand or Myanmar. Without this medicine we cannot control the P.vivax problem,” he said.
The large majority of malaria cases are caused by the P. vivax parasite, but the P. falciparum strain is more likely to cause severe illness and death. There is also a risk that P. falciparum will become increasingly drug resistant and that treatment options will run out, Nosten said.
Last year SMRU treated 32,000 cases of P. vivax and 4,600 cases of P. falciparum in Kayin State. So far this year, 17,000 cases of P. vivax and 4,000 cases of P. falciparum have been treated.
According to the World Health Organization, between 2010 and 2020, the number of malaria cases in Myanmar was reduced by 90 percent, the number of malaria deaths by 99pc and the number of indigenous malaria cases by 86pc. In 2020 Myanmar had achieved near elimination of P. falciparum, meaning fewer than one case per 1,000 people.
“In fact it feels like we are going backward and we may face a situation similar to where we were in the 1990s,” Nosten told Frontier.
This sharp reversal of past progress in Myanmar since the coup stands in contrast with strides made elsewhere in Southeast Asia.
Marking World Malaria Day 2023 on April 25, WHO regional director Dr Poonam Khetrapal Singh wrote that Southeast Asia “continues to lead globally” in working towards the WHO target of reducing global case incidence and mortality by 90pc or more by 2030.
“By the end of 2020, the South-East Asia Region was the only WHO region to achieve a 40 percent reduction in malaria case incidence and mortality compared to 2015,” she wrote. Bhutan, Nepal, Thailand and Timor-Leste were reported to have the potential to eliminate malaria by 2025.
The WHO’s most recent malaria update report covering the fourth quarter of 2022 for the Greater Mekong sub-region notes that only partial data was available for Myanmar.
The BMA’s Nay Htoo says the entire healthcare system in Kayin and Kayah states needs stability to deal not just with malaria but all health emergencies.
“Health systems can only be built well when there’s no conflict. If these wars go on then we will face many difficulties in providing health services,” he said.
Nosten says the conditions needed to reduce the incidence of malaria along the Thai-Myanmar border lie in the hands of political leaders, not local stakeholders.
“Nobody knows what the future will bring but without political will, we can expect that the situation will get worse before it gets better,” he said.
* denotes a pseudonym for safety reasons