 Ddau'ch i'n gwneud yn ddweud, ac rwy'n ddweud y dywed. Dwi'n rhoi'r dyma cael ei ddweud y dywedigol sy'n ddyn nhw'n ymddiol fel dyna'r dyma sy'n fuddiol, bo'r dyma o'r ddyn nhw'n ddysgu'n cyfaint i'r drwng, ddyn nhw'n ddyn nhw'n ddyn nhw'n ddyn nhw'n ddyn nhw'n fennodol drwng 50s, 60s, 70s, a'r ddiadwch yn cyflolol, yn y bryd, ac yn y bwrdd Cymboedd. probably some time in the 1950s, it spread across Southeast Asia, marched across India. By the late 1970s it had arrived in Africa, and by 1992 it had reached the western seaboard of Africa, and it killed literally millions of children. So the parasites that killed millions of children in Africa had their predecessors in Asia. The drug that followed, chloroquine, was sulfadoxin pyrimethamin, and the main resistance mechanism to that drug emerged in exactly the same place, and followed exactly the same path. So you can see why we're extremely worried, rightly, that the same pattern is now beginning to emerge. So, as ever with resistance, there's a long period when you don't know it's there, because its multiplication is logistic. So we first really recognized Artemisian resistance in Western Cambodia in about 2007. Which is nearly seven years ago. Since then, it's become clear that the extent of resistance is larger than we had hoped it would be. We'd hoped initially it would be confined to Western Cambodia. That's not the case. Resistance parasites are prevalent on the western border of Thailand, the eastern Myanmar. How far into Myanmar I think we should discuss because that's the critical, I think that's the critical extent of the disease. It's also prevalent in southern part of Vietnam, and probably is beginning in the southern part of Laos. The problem with it is that Artemisians are our best anti-malarial drugs. We're the center of all treatment for falcipran malaria. We use Artemisian combination treatments, and artesunate has been shown to reduce the mortality of severe malaria, which still kills 2,000 people every day, by one third. So these are critical drugs, and if we lose them, we're in a very, very serious position. Fortunately, malaria in the area is still curing down, but there is a narrow window of opportunity, I think, to intervene. Whether that window is closed or not, I'm not sure. But certainly my own view is that we're having, there's a lot of talking, lots and lots of meetings, but not quite so much action. Bernard, how about a perspective both from your current official role as the Deputy Coordinator of the President's Malaria Initiative, but also as a longtime expert in the field of malaria as well? Yeah, thanks. And again, thanks to CSIS for organizing this, because we all need organizations like CSIS to continue to raise the profile of what's going on in the region, because that helps those of us working in the US government side to put the full force of the US government behind this. So happy to be here and happy to be with Allen and Nick who have spent large parts of their career. Well, Nick, everyone, probably no one more known in the Mekong region from malaria than Nick. I'm sure sometimes he has felt like Cassandra wailing at the walls, but I think his voice continues to be heard, and I think the sort of what you see happening now is very important as far as not only the US government, the Australian government, the British government, the Global Fund and other sort of rallying behind this. As you heard earlier today, the US government involvement in the region on malaria is not new through CDC, and I know Allen with Walter Reed and the US Navy Laboratory research thing. That primarily and USAID, most of the funding through USAID beginning in 2000 was primarily focused on creating country capacity to do the sort of surveillance for drug resistance that Nick and others have been doing for many years. Also the quality of anti-malarial drugs. When the red flag went up on the Thai Cambodia border that there was a problem in 2009 PMI, which the present malaria initiative for those of you who aren't that familiar was launched in 2005 as an interagency initiative led by USAID with CDC as the main implementing partner. I think the thing that changed in 2009 as we updated our strategy was actually developing what we hope will be a response to what's going on in the region rather than just doing more and more surveillance showing that it's an issue. PMI since 2011 has increased funding to the region through the USAID regional office. You heard about the lower Mekong initiative and the health pillar. That's primarily focused on, again, strengthening surveillance capacity in countries to continue to do good quality drug studies to know whether or not there is a problem. Secondly, the whole important issue which you saw in the film of the quality of anti-malarial drugs in the region helping countries to know at a very local level whether or not the drugs that are in the shops and elsewhere are good quality are totally fake or poor quality. And then thirdly, the new component of this is actually engaging directly in trying to drive down transmission, push towards elimination, in some of the, particularly the Thai Cambodia and the Burma Thai border areas where we know there's a problem with drug resistance. In addition to that, we do fund some research presently around a rapid diagnostic test for G6PD because in addition to the problem with valve super malaria in the region there's also, as you know, VIVACs. And secondly, the new WHO call for low dose premises in the region as part of treatment for VIVACs to see how safe that will be as it rolls out. I think it probably will be safe but just to further reassure ourselves in the countries. And then thirdly, some things on vector control like spatial springs, et cetera, et cetera. We're obviously not doing it ourselves. We're partnered with the others in the region, the Gates Foundation. Our primary partners, of course, are the national control programs so having Dr Orr and Dr Hien here is important because ultimately they're the ones who are the holders of success or failures in the region and we all need to rally around them. Just to, I don't think any of us are naive. There are some major challenges here. There's technical challenges, which I know we'll be talking about more today. There'll be another discussion later this afternoon. There's funding challenges. Despite the big increase in funding to the region for malaria control, the big bulk of that primarily through the global fund, the countries themselves have obviously continued to invest their own resources in that. And then Austria, again, the FID, the three diseases funded me and Marr and ourselves. There's also many of you may be aware that the Asia Development Bank is talking about creating a funding platform for health in the region which would bring additional resources. But there's still our major resource gaps that we all need to figure out what that means and how to rally around that. And then lastly, I think there was some reference to this earlier, the sort of making sure there's high level political commitment and commitment all down through the systems, all the way down to community level, to seeing this as a problem and to make sure that whatever we try to do as external funders is effective because we're able to actually engage the local actors at a very micro level in order to be able to get rid of this problem. Thanks. So maybe a question just to see your responses. This sounds like a really important and potentially deadly problem if the Artemisthen resistant parasites that are currently found in the greater Mekong, Southeast Asia, were to spread into the Indian subcontinent or in Sub-Saharan Africa. Now, to me this has all the bearings of literally a global health emergency. And yet I certainly don't see that level of concern and action from on the global community. And I wonder if it is since this Artemisthen resistant malaria, let's be realistic, has no chance of causing problems in North America or Europe, but every chance of causing problems in Africa or India, you think that might be a reason why this isn't being considered at the same level of SARS or pandemic flu and because we're not at risk and others are? Nick, what do you think? I agree. I think another point about malaria, particularly in Southeast Asian region, it's a rural disease, so it's not affecting us who live in the cities or the policymakers who live in the cities. I don't think it has quite the political pressure that say H5N1 or H7N9 would have. I also think there's a... We're not very good at really serious, rapidly emerging health problems to be honest. We're quite good if the tempo is slow, but I don't think you can fight this war by committee and I don't think we can do it just by doing a little bit more of what we do already. I think we have to take a radical approach to this. It's like cancer, it's spreading, you've got to take it out now and that's going to move us out of our comfort zone. And we're really not good at doing things where we don't feel really comfortable and can achieve a consensus and have a strong evidence base. Of course we can't, we're going to have to learn by doing. It's a war and I don't think we're fighting it properly. Well, for those involved in non-communicable disease, I'm not sure cancer is the best corollary here since we're not doing a very good job on that either. But yeah, I agree. I mean, but this is a challenge not specific just to this problem. It's a challenge we continue to have. I mean, obviously most of PMI's focus are in the 19 high burden countries in Africa where we provide support. And as Nick pointed out, the challenge in country by country is that this is a disease that is primarily very rural, frequently beyond the edges of the formal health system and the political systems. And in the Africa region, it primarily kills young children and very poor families. And they don't have a big voice in the political system in many countries. So I think that's where we all, from outside and inside, need to continue to point out that this is an issue. As Nick pointed out, there is a direct relationship between what goes on in these high burden countries in Africa. I mean, first of all, drug resistant malaria is important for people in the Mekong, obviously, because no Cambodian, no Vietnamese, no Thai, no Burmese, nobody should die from a drug which is perfectly treatable and to a large extent preventable. But the Mekong region can, as part of the global public good, can give the world a very good thing if you can show that falciparum malaria can be eliminated and beginning particularly in areas where we know there's drug resistance. And in the process of doing that, I think what you learn from doing that will have major implications for how we do malaria programming and support in Africa and also in the Americas. The fact that this doesn't get the same level of interest as SARS is just a reality. I mean, SARS, which spreads through airplanes, spread very rapidly, et cetera, et cetera. And frankly, I don't think that when we keep hearing that mosquitoes fly across borders, it's a very, it's actually people who move across borders, that's a problem. I mean, the mosquitoes fly at most two kilometers with a strong wind. So if you wanted to limit yourself to that area, we could have a much more efficient program. But it's really the people moving across borders we need to focus on. I don't have the answers to this, but I am optimistic. I think we're all optimistic who wouldn't be in this business. I think there's good evidence already in the region, as Nick's pointed out, of overall decreasing malaria transmission in many of these areas. And lastly, you know, the bottom line is the US government is fully committed to doing something about malaria. PMI were $650 million this year. Our Congress has basically appropriated every penny the president has asked for in addition to some. There's no indication that they're going to back off from that. But this is year to year funding. So despite the budget problems here, all of you who, through your own wake and influence, the ongoing funding commitment from the US government, that will be important. All right, thanks. So the, you know, in the earlier years, in 2007, 2008 and 2009 and such, the, a lot of the response to this problem was, there was a word used containment. This was part of the initial World Health Organization documents and some of the strategies. And I think many of us in the community were always a little puzzled by the use of that word containment and what it meant. And what exactly do you think now is needed? We, some have spoken about a very specific and targeted effort to eliminate the falciparum malaria, all falciparum malaria from the area, because that's the risk point. And maybe Nick, you could start with sort of discussing maybe the origin of this word containment and what do you think about a truly targeted effort to elimination at this point? I don't think we can contain it in the region indefinitely because unlike many other parts of the malaria endemic world, vector control interventions are not as effective in the region. The vectors bite early in the evening, commonly outside, so insecticide-related bed nets which are a very, very important part of malaria control in Africa, in West Asia and South Asia, they're not quite as good in Southeast Asia, so we absolutely rely on the drugs, the drugs which are failing. And so as you drive malaria down, which is this window of opportunity that's narrowing, you basically distill down to the most resistant parasites until the last one is the most resistant. And whilst you can drive it down, we have hope. Once it reaches a higher level of resistance where the drugs don't work, we are putting it technically stuffed. So I don't think we can contain it, you have to go and get rid of it. Fortunately, I think that is feasible. Whether it's going to happen, I think depends a lot on the politics and that's why we're here today. Others may say that it is actually unfeasible, but the number of cases in the area is relatively small and the countries have done very well in the control programmes and there has been good news, there's increased deployment of effective diagnosis and treatment and the burden is still coming down. But when we start to turn the corner and with further roll out of effective treatments, disease starts to rise, which we've seen before as I've told you, then without new interventions and we don't have any immediately, we don't have anything that is as good as the ACTs in the cupboard for the next five years, then we're in a really difficult position. So we're in a race against time. Bernard, maybe some additional comments to that or other views? No, I second that. What Nick has just said, I mean I think the original term containment was unclear what success would look like for them. Let's face it, we know where the resistance is at the moment because that's where we're looking and we can't look everywhere. So I totally agree with Nick that what we need to do is concentrate on getting rid of the parasite from the region using what we have on hand. I think there is some experience now that you can go a long way and maybe the whole way, not only with the tools, but with new ways to actually deliver those tools. So we've had many different sort of causes of this Artemisthen resistance have been proffered over the years. They all revolve around basically lots of parasites encountering not enough drug and there's various reasons for this to include the multi-day regiments that are used. People don't complete those regiments. We have some dosing challenges with some of the regiments, maybe the dosing regiments we use aren't good enough for kids that have higher parasite burdens. Certainly the problems with substandard medications or Artemisthen monotherapies. So there's a long list of things that have all been offered and there's some proof to show that there's what is the attributable fraction of that, but if based today on what you know, which one of those do you think actually is maybe the most important and if you could do one thing tomorrow to sort of turn the tide a bit here, what might that be? Again, we'll start with Professor White. Well, there are many factors, but if you want me to pick one, I think it is the exposure of lots of parasites in an individual person to not enough drugs. So, for example, if I have 10% parasiteemia, 10% of my red blood cells are infected, I've probably got about half of all the parasites if I was sitting in Cambodia in the whole country. It sounds weird, but that's because of the very logarithmic distribution of parasites. So resistance comes when a person with lots of parasites takes a little bit of drug and artesunate has been, or artemisenins have been available as monotherapies and single tablets have been widely used as such for nearly three decades. So I think that was the pressure that led to resistance. And then the, and this is no one's fault that the parasites, the genetics of the parasites in Southeast Asia basically, they're more likely to develop resistance to anything than parasites elsewhere. So their genetic backbone is unusual. Obviously you need enough drug to do what you want the drug to do and that's an important thing. And again, that's where Nick and his group have been at the forefront of helping to sort this out. I think the thing that sometimes in addition to that, once we know that, the thing that I don't want to say it's been overlooked, but there doesn't seem to be as much attention paid to as then, well how do you actually get that drug into that person? Particularly in an area where you have a very vibrant private sector and people are not necessarily going to clinics where, you know, clinicians or whoever may be trained to do that. And that's where frankly a lot of the poor quality and fake drugs are being found is actually in the private sector. That's a real challenge in the region and I think again we all need to work with countries to strengthen their capacity to deal with that issue. And secondly, the migrant slash mobile populations, we and PMI working with the countries are really trying to, and some of the NGOs in the region are really trying to understand that both through village health worker models where you're actually able to get whatever the tools are out to a very much more local level, but also through some other innovative things such as part of it is letting people know, for example opening, there are border clinics on the Thai Cambodia border and also on the Thai Burma border now, but people need to know about those. So how do people know about that if they're moving across the border? How do they know where they go particularly since there's not a political framework which would allow them to go always to the local clinic? So I'll just give you an idea of the sort of stuff that we're doing. A lot of the workers who come from across the Cambodia border into Thailand actually it's long distance taxi drivers that are bringing people across. They're not like walking across necessarily themselves. So we've been through one of the NGOs working with long distance taxi drivers so they can actually be part of the education of these migrants only where they go etc etc. There's lots of examples of that sort of stuff but I think in addition to knowing what the best drug is and what the proper dose is for that age, we also need to know how to get that drug into the person. So there are lots of groups that have great interest in both the overall health and security of the greater Mekong region and maybe specifically on the malaria piece. Certainly my own organisation, the Gates Foundation, has been very active in the area. And maybe Nick, you again have a perspective since you've lived in the area now for I guess over 20 years and do you think all of the quote external folks, like the foundation and the global fund and Ausaid and DFID and PMI, do you think we do more harm than good or more good than harm? And what could we do differently that might actually make things better? I think on balance you do more good than harm but I think the without being too cruel I don't think there's been wonderful co-ordination despite all the fine words between all the donor agencies but I also think that the structures for delivering, the executive structures for delivering something radical are just not there. So it's very difficult to, for example, if we wanted to eradicate smallpox in the region today it would be very very difficult. We just don't have, we haven't set up the structures to move quickly and effectively and to cross borders despite endless meetings about cross border interaction let's be honest, they're not that good. So I'm just not sure we've got the mechanisms in place to effect a radical strategy but I think there is, on the good side, it's been very encouraging to see the increase in donor interest and money on the table and the global fund 100 million I hope is going to be effective but I'm not to be honest very optimistic. I think in following on with I think some of the comments of our colleagues, Dr Orr today and last evening as well this perspective at the country level when you're on Monday you meet with the Gates Foundation and on Tuesday with PMI and on Wednesday with DFID everybody has their own, you know, here's our style, our template for our, here's our report structure and I've seen a little bit of this on the other side as well and I, you have to, on a good day you have to have a sense of humor right? So I agree, I think there is a problem here in terms of coordinated action I would say that you know, just in the last year or so there's been a lot of discussion between ourselves, the PMI and Ausaid and others there certainly is an attempt to think about this but you know, Bernard what do you think about just a broader sense of what Nick was talking about in terms of do we really have the structures in place for this radical action that I, you know, I see this as a public health emergency and if you were, if you were a president for a day what would you do? Of which country? Yeah. Your choice. Well, I, you know, everyone sort of like the weather everybody talks about coordination nobody does anything about it to a large extent but I think the problem we have at the moment is well first of all I would ask that the research community in the region also be coordinated so that the rest of us know how then best to flow our funding so we don't end up whatever Gates might fund PMI should maybe fund something else or plug the funding gap and and I know Nick is one of the major research institutions in the region and Afrums and all the other the national research institutes they themselves need to have some sort of a coordinating mechanism because frankly I think that's one of the least coordinated parts sometimes I see when I go in donor coordination which is where I had I'm wearing at the moment I think the challenge we have at the moment is there's probably too many things trying to be coordinated the global fund malaria grant is setting up a new structure called the regional steering mechanism which is to coordinate the 100 million dollars from the global fund there's the new Asia Pacific leaders malaria alliance with the president of Vietnam and the prime minister of Australia which will be set up under the Asia Development Bank and there's the WHO regional hub in Phnom Pen which is going to be coordinating the technical aspects of this so we have lots of different coordinating mechanisms at the moment and I don't have the answer to this but I think at some point in time how does this all come together but we also don't want to move away from the fact that most of the coordination despite the fact the need for cross border collaboration you know there's still a lot of malaria inside the borders of these countries in PMI we fund the national air control program gaps and we work with the national air control program to update those plans as new tools or recommendations from WHO and others come along so our coordinating body is actually the national air control plan and I can't speak for the other bilaterals but I think that's the intention as to going back to the three ones one national air coordinating plan one national M&E system and one national leadership how that fits into all the discussion I think the challenge at the country level is country like Thailand where malaria in large parts of the country no longer is a problem if you talk to Dr Weechai in Thailand their challenge is getting their own government to recognize that it's still a problem and they need to remain committed to this I think any one of these countries we from outside whether it be with new tools or whether it be with new funding can only do so much it really gets down to what's going on at the country level and making sure that there's coordination between the ministry the ministry of finance there's one plan et cetera et cetera so I think I'd like to open it up to the floor now and to see about some questions I know there's lots of folks in the room who've had experience in the area and lots of representatives in the countries and we can start with a couple questions and as previously if you just identify yourself and good morning ladies and gentlemen my name is Rosemary Seguero I'm the president of Hope for Tomorrow I'm past here in Washington and I come from Kenya I agree with Dr Penart on collaboration coordination and funding I think as we are here all the organization that do funding should look at net so that they know what they are funding if it's a mosquito net it's a mosquito itself or it's medication because I come from Kenya where malaria comes from and we thank the United States government for supporting Kenya so much and African countries that are involved in malaria and HIV Aids so how do you work with the local people on the ground they know more about what is needed if it's through common hygiene of cutting grass or removing mosquitoes or water stagnant and what I think most of the funding should go to the local people even where we are talking Vietnam they should coordinate with the government and especially the grass root people who understand the problem of malaria I think the common people can fight malaria collaboration with the government so how do you work with them and how do you work with us looking at funding collaboration and coordination thank you yes I would like to ask a question this is from the implementation and the practical point of view and as you may know that we try very hard whether it's come from donor from the government in order to have our people to tackle this kind of not only drug resistance but also we have to think how can we put together the effort to contain the malaria drug resistance together with the strategy for the malaria elimination together but as you may know that no matter what we talk between the donor and the government on how we have but the main point is the people that they really need help from us and often time for the day to day working I see that we talk a lot so this is come from the first comment that you raised at the beginning we talk a lot but we do less so the people cannot wait for our talk and based on my experience is that by the time we start talking and by the time we actually get into the implementation it takes very long time and the people may already die so is there any mechanism or is there any experience that we can learn that the action can take really quick when we identify the problem forget about the politics forget about the whatever the complexity or whatever that we can really get into the people in the community because people in the community they really need help from us because for example if I live in the community and I get malaria where do I go so I should know I should receive enough information about the healthcare services I should know whether the drug that I'm going to take it's really real drug that is not make me to be the drug resistant for example like this so is there any idea or thought about this I think this will be more useful for the practical point of view thank you Can we take a couple more questions and then we'll Good morning, so Lee Pan-Wong from United States from a copiar promoting the quality of medicines with respect to the quality of anti-malarial so that has been one of the key factor I think contributed to the resistance that we are facing today just for example the threats is there the issue is there about the spread of the anti-malarial resistance to other regions now if we look at the practical part only one piece say bending monotherapy of all anti-malarial has in the region a policy in place looking from the political point of view looking from the programmatic point of view looking from the technical point of view the malaria control program issue a banned monotherapy for example and the little has been consulted with the other sectors like a medicine regulatory authority who has the function overseeing the quality of medicines certainly with the higher level there's no mechanism whereby the coordinated way among these cross functions work together that's one piece of the impractical in the country level now when we talk about the donors they come with different time with different mandate and objective as you know the panel mentioned coordinating among them also create a challenge at the country level because they come in different time even though they are talking about complementing each other on the efforts but at the country level it's very difficult for them what to please who to please and people are keep dying and the other point that I would like to make here is that some agencies claiming they know about the quality of medicine how to ensure it from the start to the end users level and some donors assign the money to them to procure to distribute and without monitoring we know there's general product also substandard we know that we have the evidence for it so this is one of the practical issues at the country level that need to be addressed so I would like to hear from the panel some thought about this thank you I'll try to be brief I'm a physician mylariologist just retired from the U.S. Army Collinord is my name I'm now at University of California San Francisco militaries are large structured workforces and might be part of the answer to Dr White's comments but my question for the group is is how can the U.S. military help and how can local militaries in Southeast Asia help one more we'll go right here I have already got some more questions how to work with private sector to ensure that appropriate treatment to all military operations because it's one of the bigger challenges for us private medical practitioners also increasing in our country many migrant workers or people who go to the private sector first before going to public sectors now to work with private sector to ensure that that appropriate treatment on military operation thank you so let's uh we'll just pause for a minute and try to respond to these questions and we probably will have time for a few more I think the first two questions really came around what I call the grassroots action of local people so these are the folks on the ground who may be living in these rural areas they're the ones at most risk of actually getting malaria how do we best access those folks educate them provide them directly with services and and really have them become the best advocate for their own sort of healthcare we're dealing with a lot of this in africa now maybe start this time with Bernard and just say and ask that question any thoughts again from either your official or your personal experience on how that might be best done yeah and again that that is a crucial issue because no matter what the research is no matter what getting the the right tool it's how do you then make sure that tool is accessible to people at a very local level and malaria is an important disease to work on for that very reason as we've already pointed out to the colleague from Kenya it's it's not Nairobi it's out in these rural areas that that's where the problem is our experience and I think it's also the experience of the global fund even though I see Scott here I'm not going to speak for the global fund but we all you know when we talk about the national air control plan most countries now recognize that despite sometimes weak government systems a lot can be done if the the national air control plan engages effectively the NGOs, civil society and the private sector in these countries our experience in the Mekong with some of the NGOs we're working with and certainly in Africa is that out there in these very rural areas where there may or may not be a clinic available a lot can be done through training community agents whether they be called community health workers whether they be specific for a rural area for others over and over and over again you see that at a very local level if there's someone in the community who has some minimal training and has given a good quality rapid diagnostic test and good quality drugs and and they're being supported to do that some pretty major things can happen when it actually comes and that's not a run around the health system that's actually an extension of the health system in a very logical way and that's not something that frequently the government health systems themselves can deal with in a very rapid pace but there are most countries have more capacity to do these sorts of things then they've been able to mobilize but I think certainly in the discussions we have with the global fund and with the UK government and I'll say these are the sorts of things we're also looking at secondly the private sector lots of experience in Africa with the extractive mining industry and also agricultural industries like the sugar sugar plants in Malawi for example where the private sector themselves are frequently more than willing to invest in malaria prevention and control for the population they serve that frequently is not only their direct employees but the community of their catchment area and there's actually some very good data from Africa looking at the return on investment for that the bottom line is it's a great return on investment I think the importance of the private sector in the Mekong at the moment very dynamic you know new roads dams et cetera et cetera et cetera provide some opportunities and also frankly economic growth provide some opportunities to figure out how to best engage the private sector around some of these issues that's best done obviously by the government itself with us supporting that not people from outside and then secondly there's also a risk particularly in the Mekong if you look at what's going on with rubber plantations now being set up and reintroducing the vector in areas where before it was less of an issue and we've had some experience in PMI working directly with these plantation owners to try to deliver services to migrants when they first get there so I don't have the answer to everything all I can say is that if we don't pay attention to this we can have great tools lots more meetings as Nick says lots of coordination we can coordinate ourselves all over the place but if we don't figure out I mean the end user the goal of this is actually at a very local level to get the goods to those folks and that's going to require engaging all the capacity at the country level Thanks Bernard Nick, anything to add to that? A little bit I think the first priority is provision of effective diagnosis and treatment and the problem for example in western Cambodia is that there is no treatment currently recommended that will provide 90% cure rates in fact cure rates at best 70% at the moment so government here has a role to allow the research to take place which will find better regimes so there's coordination there I think the second priority is if you've provided effective diagnosis and treatment then vector control and other interventions if their funding provides it but then the third point is that we've underestimated the epidemiology of malaria in the area and there are foci quite substantial foci of asymptomatic transmission and here people don't know they're infected so the community doesn't know and this is going to require substantial community engagement if these people who are the source of the malaria in the unstable endemic areas are going to be to understand that they are the source of the infection and be willing to receive treatments and this I think is a major major task ahead of us one we haven't really engaged with at all I'm glad you brought that particular issue up because I think that may actually be one of the sort of these new steps and new strategies that really needs to be introduced into these areas about the community engagement and really targeting the asymptomatic reservoir and I think you also made illusion to another issue which in a certain sense we need to learn by doing which means to be fast and flexible but still very transparent and visible and I think the structures have been put in place globally all for the best intents and purposes in terms of multiple review steps and institutional review boards and national review boards have actually become paralyzing to the extent that essentially nothing can get done and I think the countries all countries including the United States need to take a really careful look at this to try to liberate this a bit that doesn't mean that things can't be done in open transparent fashion but if it takes 19 months to get a protocol approved then there's hardly a reason to do it going forward I think just to there's a couple of other questions that came up and Colin had asked a question about the role of militaries both as a potential source or reservoir of parasites because they're a highly mobile population and is also as a large and structured organization that could actually be very effective in the elimination efforts and maybe Nick start with you and just your generic feeling and then just any thoughts on the role of the militaries in the Greater Mekong I think if we're going to really deal with this alarming situation seriously and more importantly rapidly and value speed then we're going to have to mobilize sectors way beyond the health sector and which means moving out of our comfort zone in the health sector and I think the military civil society university students everybody's got to be involved this is a really serious problem and it is a problem not just for Asia I think the whole world or the whole malaria potentially malaria endemic world needs to pitch in here and help provide the political support and encouragement to the region the Southeast Asian region which is going to have to take on this tough task I'm wondering some additional comments Yeah so obviously the military is important in these regions because when we keep talking about the border areas and frankly that's frequently where the militaries have a big presence and there's not always a great linkage between the civilian military populations in these countries where ironically sometimes I think there's a false assumption that somehow the military always has it better than the civilian population when it comes to their access to good quality drugs and diagnostics and prevention and I think there's lots of examples where that's not always true it's not something that's easy for where I'm sitting to deal with but I think our I know there'll be a session today on Mill-Mill collaboration and I just want to that needs to be Mill-Mill civilian collaboration because it's only going to work if we bring all of these things together most countries I mean when it comes to pure funding bases just FYI for example in Africa and then I've talked about the national air control plan if you look at in a place where we know bed nets work basically to come up with how many you estimate how many bed nets you need for a country like Kenya they actually take the population at risk basis and they then use a factor of 1.8 persons per bed net they don't subtract the military population and then do that and none of the countries am I aware of are they subtracting the military population when it comes to their estimated needs and funding gaps the problem is that there's not always a good linkage between then the funding the civilian population and the military population we need to do a much better job on that I'll also just point out that all sorts of things can happen which I mean there's I know CDC Paddy's here just published an article on a case of Falf-Syphram resistant malaria which showed up in Guatemala a country where this is you know Central America still has 100% chloroquant sensitivity as far as we know and this was a a military person who had been deployed to Africa as part of a peacekeeping force so why militaries themselves can't either do presumptive treatment for everybody coming back from a malaria area or I mean those of you spent your careers in the military I'm sure have some good ideas about that but I don't know why it's just not doable it seems so straight forward in some ways to me but it's not happening yeah I would agree that's you know certainly in the current era there's several global militaries that are now participating in the UN peacekeeping operations and so whether it's Cambodia or Guatemala or others are actually being deployed to Sub-Saharan Africa on these missions and then returning so this can go both ways I think very mobile populations so at risk if I can take the liberty of combining sort of the last two questions one was on the Artemisthen monotherapy and the other was on the private sector and I think they they certainly can and very much are linked and the private sector in some ways I take the the yn and the yang of this it's the source of you know some of the the poor practices but it's also a source of great accessibility the private sector can be everywhere the public sector has difficulty being everywhere so how do you take advantage of what the private sector can offer and yet avoid the downside which is the proliferation or the use of monotherapies and then just recognize in our own country we know very well that you can have great guidelines and great policies and some of us have worked on guideline committees religiously and feel great about it and then you go out and survey and what's done in practice in the community and you realize that it's sometimes dramatically varies from what's in the guidelines so this is not a unique problem to rural Cambodia this is a generic problem as we deliver medicine and maybe Nick take a stab at that yeah I think this is a difficult one the regulation of drugs in many endemic areas is weak the ability of national air control programs or all health programs to monitor drug quality is very poor the number of laboratories available to do these measurements is limited but it's critical and I absolutely agree that with Professor Hean that the private sector is still a very important component of of all infection treatment but malaria is one of them so I don't have any magic solutions other than to say I think that the legislation needs to be strong I think that Artemisyn in monotherapy that the ban on Artemisyn monotherapies in the private sector was a wise move but it's been one that's been quite slow to come to completion and they are still available in the areas in the southeast Asian area providing drug pressure so I think further further persuasion but also I think we need to be quite creative with the private sector to provide incentives too as to how they could as to ensuring correct prescribing practices the very difficult issue of how we can incorporate diagnosis in the private sector these are big challenges which I don't actually have very good answers for Bernard Comets Sure I'll just add on what next but first of all I think we need to be I get a little frustrated sometimes when we talk about the private sector because it's not clear always what we're talking about in this particular case obviously we're talking about presumably private sector shops delivering anti-malarials but we also talk about private sector that's doing the manufacturing of these anti-malarials private sector that's doing agriculture and we tend to the reason I bring this up is because it's important when we talk about the private sector what are you actually talking about for example in the Africa setting which I know a little bit better than the Mekong but I assume similar issues growing the Mekong you can have licensed shops unlicensed shops grocery stores and itinerant drug sellers your ability to actually do something about that is obviously quite different if it's a licensed shop if the government regulatory authorities have some resources to do their jobs then you can figure out what you should do to make sure there's actually good quality drugs in those licensed shops many countries have not only banned monotherapy well not many but some countries have banned over the counter cells of anti-malarials in certain settings in the Americas and I think we're going to be seeing as part of an elimination strategy we may start seeing some of that and some parts of Africa as well that's a different thing when it comes to people with just going around selling drugs through the camel or a horseback that was just going to be if nothing else demonstrates the big demand for these drugs I think the more we're successful in actually rolling out diagnostics training people educating people that not everything is malaria hopefully some of that demand will start decreasing there will be less incentives for some of this so going back to the USP work which in the Mekong region you know they've tried very innovative things because not all of these shopkeepers selling drugs actually want to sell poor quality or fake drugs they just don't know that they're poor quality or fake there's a new technology out there which some of you may be familiar with that FDA has been involved in helping to evaluate which may make it possible to do this even a bit quicker we've been funding USP and others with mobile labs and training people out in rural areas to actually use these labs to actually go in and see what's going on I know USP at one point in time when I was out in the Palin area had done something creative here in the United States we have something called the PDR which every physician you know when the patient comes in and says I'm taking a blood pressure med but which one is it what's that little blue one you know it's a little they know so you actually have pictures and you can go in I know USP tried that I don't know how successful it was but I think it's an interesting effort to actually help the shop owners themselves know what's a good quality and what's a poor quality that they shouldn't be buying so I'll just stop there I just think we when it comes to as Nick said it's not just about banning that's an easy thing you know it actually is about education it's about the supply chain and it's about regulatory enforcement even here in the United States if we didn't if shops weren't afraid they were going to lose their licenses if they didn't abide by these then we would see a lot worse stuff than we probably already exist over in CBS that's right I know there was a few additional questions so I think we have some time there's a couple here thank you my name is Jeanine Wynwood with Voice of Vietnamese Americans and I was thinking of the civil society but you have touched on it so my question is can we utilize utilize this as an opportunity to build infrastructure in many different ways to deal with communicable disease and many other diseases in the Southeast Asia and one of the strong infrastructure that I've heard that we're lacking is the human infrastructure and I'm very thankful that Dr Nguyen is here because I think from the concern of Dr Orr and Dr Nguyen Cambodia and Vietnam share many same challenges I understand that similar with the question raised of the role of military and civil society the infrastructure networking in the community is there a way that we can work with Cambodia and Vietnam and Southeast Asia to build into education from elementary school up into many other community and especially Vietnam I know we have a very effective secret service every six Vietnamese there's one or two secret service built into the community and right now I understand that even in the pagodas or in the churches there are priests and monks that are following the communist party instructions is there a way that we can use them effectively to help the people that will actually give out the good positive incentive for both sides mutually benefiting for the people and would really help at this moment in time so can we take this opportunity to talk about the long-term infrastructure building effect that will help everybody to contribute to a better more positive effect in the future long-term future thank you I think there is one question right there thank you very much my name is Lamine Sar I'm from the Gambia with my colleague Dr Jialo here we came just because we wanted to understand how this partnership is actually shaped and structured and how it walks out in the Mekong area because we are very much interested in similar relationship that do exist within the African context as well but my question is given this situation that's happening with this drug-resistant malaria and Africa's history of dealing with these issues should we push the panic button now how do we begin to communicate these issues so that at least from a preventive infrastructure development Africans we can begin to walk on an initiative to be prepared at least to deal with this because we already deal with drug-resistant malaria issues in the continent thank you so I think we can take one more question over here on the corner thank you Mike McDonald Health Initiatives Foundation Inc and we work on the Vietnam resilience system I'm just wondering I was getting an impression about something that I don't think you meant to imply but I just want to clarify under conditions of global change we have a lot of mobility and we have climate change and under those circumstances you had implied that the mosquitoes will not have much range but in fact if the drug-resistant strains come into areas in which there are already mosquitoes that can carry that a malaria that form a strain of malaria into the population then couldn't we have actually malaria moving into the Americas through the blood like the one O'Gawa came into Haiti in the gut and what we've seen is that the mosquito populations appear to be going north so why wouldn't we see actually a much more dynamic scenario which might be harder to control Great, thank you everyone for those questions I think we can start with the first one about the longer term capacity both infrastructure and a lot of human capacity and maybe the way to frame that is that in areas like much of Southeast Asia now where the actual prevalence and incidence of malaria is low and getting lower that at the village level malaria may not be the number one problem at the village level or even in some of the individuals and yet we're very interested in these drug resistant parasites and our desire to eliminate them so our concern and desire may be greater than sometimes what's seen at the village level and one of the ways to work on that is to make sure that you're always addressing the problems that the people in the at the community feel are their major problems and making sure that does get addressed but then also making sure that you build in this malaria piece and of course we hear constantly this is a more of a multi sectoral issue in terms of education as well as a longer term issue which means the human capacity and training and it's not just expatriates or people from the capital city coming in and trying to help so again someone with a lot of background in the area nick any thoughts or a little perspective on that view well I hope we don't have to have a long term plan for this for our tumisian resistance but I'd like to get rid of it first so that community health development can concentrate on other things but I think Alan's point is an important one that often even in these particular areas where our tumisian resistance is prevalent it's not the most important problem and so the education and involvement of the community and understanding it's a bit like vaccine coverage here you know you don't see measles anymore you don't see mumps you don't see whooping well you've seen whooping cough actually coming back but you know how do you how do you inform people of the need to keep these nasty diseases away I think that's a big challenge and we've got to do that and I hope we're not still talking in 10 years about the need to develop community involvement in malaria control in the area I hope we've got rid of it Myrner, do you have a thought on that as well? Yeah I can agree I think that there will always be this well there is a tension at the moment and it will continue but it's an important tension between the need for an immediate coordinated robust response to a real global health emergency the emergence of Artemisian resistance in the Mekong region and it's the possibility of spread and or arising somewhere else elsewhere versus the need to the longer term view of building up capacity but I mean the world of global health has had similar issues in the past I mean you know immunization programs for certain diseases and that I think it gets into the governments and everyone else needing to create some space because what you might need to do in a shorter term for malaria elimination whether it be mass drug administration or whether it be some new vector control method may not be something you're going to as Nick was saying need to do five or ten years from now so some of the activities just need to be recognized as being a bit they're probably not going to build up long-term capacity on the other hand I think most of it I guess this is where the lower Mekong initiative the health pillar of USAID where PMI is is all about just exactly that it's about how do you then create a longer term strategy towards addressing health issues in the region and again the the mobile population are going to be affected by malaria they're being affected by other diseases as well and I I think we can take the last two questions and comments and combine them a little bit because I think they are about the mobility and spread and it's we talk about mobility and spread of drug resistant parasites from southeast Asia but we also have to recognize that we could have what we call de novo emergence of drug resistance to Artemisans both in Latin America South America and in Sub-Saharan Africa I think some of the conditions that would be amenable to that do exist and that that drives to the larger issue of elimination or eradication globally and then I think I don't think anyone anyone I won't put words in Bernard's mouth but I I don't think anyone was trying to imply that mosquitoes can't travel from point A to B but in the grand scheme of things it's really people moving it's the plain loads of Indian expatriate workers going from Delhi to Dubai and that's where the large movement of parasite populations were to occur so maybe just a last comment from my panelist here about any issue on the mobility and then maybe a closing thought or two from each of you Nick Yeah so one technical issue which hasn't been addressed is whether the southeast Asian parasites will readily go into vectors elsewhere it sees an obvious question but actually mosquitoes are very picky about the parasites that they'll take so this question has been suggested to spurious grant bodies grant giving bodies over the last 10 years and nobody has actually funded it but it's actually critical in terms of how you deal with potential for spread does the person who's working in western Cambodia in a forested area who carries a parasite to Bikina Faso is that person infectious potentially to the Anopheles Gambi mosquito so I think there's some there's some technical issues but the we would be we would be wise to assume that it does transmit and we would be wise to be very careful about both the mosquito and the human potential the dark side of my character rather wishes that there was a little bit of incursion of malaria into Europe or North America because it would certainly gain people's attention and it would easily be controlled but it certainly might help us in the region and I think that brings on to this gentleman from the Gambia who says what can Africa do I think what Africa could do is to support the Southeast Asian countries and provide political pressure because as we've heard you know within the ministries of those countries malaria is is fighting pretension with other diseases and may not have the highest priority but what is Asia's problem tomorrow today rather you don't want to be Africa's problem tomorrow yeah I was just thinking George Clooney got chlorachlorine just at malaria not once but twice in South Sudan so we don't hope for that happening but it does raise the profile and we do everything we can to build on that so yeah we obviously need to keep the US malaria free but having a few people understanding the problem who at a high level helps George Clooney now I'm sure is taking prophylaxis yeah I mean just to clarify and I think what the point is that we need to get the parasites out of people and the best way to do that is with drugs and to make sure that the mosquitoes who may be circulating around with some infected mosquitoes no longer have the opportunity within that time period do this so when I say that mosquitoes only mosquitoes moving across borders that's not the major issue I stand by that again the mosquitoes only fly a couple of kilometers on the other hand these mosquitoes aren't infective we don't care where they fly the issue of climate change is something obviously of big research area but I think the climate the ecological changes in the Mekong are what's really important unfortunately a lot of the success we've seen a place like Cambodia part of that's related to cutting down the forest because these are forest breeding vectors and dwelling vectors but that's now being reintroduced in some of these issues as part of development projects and I mentioned the rubber plantations so we need to keep our eye on the ball when it comes to this and it's different different parts of the world the Gambia should you hit the panic button well I think you know in all the countries in Africa where we provide support we also provide support for drug and insecticide resistance at the moment there's no red flags but I think Gambia is a country where you should just work with your government to get it's a perfect country to actually eliminate malaria straight out and I think the Gambia could be a big player in showing other parts of Africa how best to do that so let me let me close this session and just emphasize a couple of key messages that um Artemisyn resistant PFALSipram malaria in Southeast Asia is a clear and present danger it threatens regional stability and it threatens global security the elimination of PFALSipram malaria in this region which is defined as getting all parasites out of people is the only solution for this problem and that I think the solution is really an all hands on deck this is not one national malaria control program in one country this is global partners and regional partners I hope the session has raised some awareness and some clarity for you and wish to thank our panelists Professor Nick White and Dr. Bernard Nalen thank you