Evaluation of the Tak Province Community Ethics Community Advisory Board: Interviews and Focus Group Discussions

1. Background

Research on the Thai-Myanmar border

Since 1986, the Shoklo Malaria Research Unit (SMRU) has provided basic healthcare and carried out research aimed at reducing the impact of multi-drug resistant malaria and other infectious diseases in the area on the border between Thailand and Myanmar. SMRU's main area of interest is in malaria, with special interest in children and pregnant women - the groups most at risk from malaria - and it has combined this research with the operation of antenatal clinics along the border. SMRU currently runs multiple free clinics for the Karen and Burman border population that would otherwise lack access to health care. The most distant clinic is about 120 km from the SMRU office in Mae Sot. Carrying out research and providing care along the border presents a range of unique practical and ethical challenges. This in part because the people who live near the border are mostly migrants or refugees from elsewhere in Myanmar who have, since the 1980s, moved to the border area to escape economic hardship and sometimes conflict and persecution. There are currently thought to be two million migrants from Myanmar living in Thailand (about 150 000 in refugee camps) and a further million 'internally displaced' people living near the border inside Myanmar, although numbers are difficult to verify. The vast majority of these people, who come from a very diverse range of different ethnic, religious, political and language groups, live in insecure, unsafe conditions and face a number of serious health difficulties.

Until 1995, SMRU focused its activities primarily in the refugee camps in the border area and a strong collaboration was established with non-govermental organisations (NGOs) to control malaria in the refugee population through the operation of "the Malaria Task Force" (MTF). This was largely successful and malaria is now a minor problem within the camps. As a consequence, whilst SMRU remains responsible for antenatal and obstetric care and the treatment of malaria patients in refugee camps such as Mae La, since 1995 it has increasingly extended its activities to reach out to the wider displaced populations who have little alternative access to malaria diagnosis and treatment or antenatal care. This is done in collaboration with the Thai Ministry of Public Health (MOPH) and in close collaboration with the district hospitals and the Tak provincial health authorities. In 2001-2003 the Tak Malaria Initiative, supported by the Bill & Melinda Gates Foundation deployed the malaria control strategy developed by SMRU in the refugee camps to all 200 affected villages in the province's border districts with substantial success. When the funding from the Gates Foundation came to an end, the MOPH took over the program.

The border between Thailand and Myanmar is at the forefront of the global fight against malaria because it is on the frontline in the battle against the development and spread of resistance to anti-malarial drugs. Malaria parasites found here are some of the most drug-resistant on earth and their expansion and spread is a very real global threat (research has already demonstrated that the most drug-resistant malaria parasites found in Africa originated in South East Asia) . This is particularly urgent and important in the populations living along the border because there is published evidence that the malaria parasites may become tolerant even to the most advanced artemisinin combination therapies (ACTs) now at the forefront of global malaria treatment.