The malaria cauldron of Southeast Asia: conflicting strategies of contiguous nation states.

The past half-century or so has witnessed dramatic failures but also some successes in control of malaria in the world at large. South and Southeast Asia have had their share of both outcomes, a scenario that reflects many variables in control programs: technology, management strategy, human and financial resources. However, at least equally culpable have been major wars and minor conflicts, economic growth and stagnation, inequity of opportunity, urbanisation, deforestation, changing transport and communications. The history of malaria is thus an integral part of the broader political and economic evolution of the region, as well as the story of the wisdom and unwisdom of malaria specialists. In positive reflection on the latter, systematic organisational effort using standard tools of trade has seen the gradual elimination of major malaria foci from central plain regions of a number of nations in this large region, with residual foci at forested border areas. In many cases there is good evidence of sustainability of elimination in defined areas but the differing success stories reflect in part conflicting strategies in neighboring nation states. On the other hand, physical conflicts, population migration, inequitable economic change, border instability and many other socio-economic variables can be clearly seen to undermine the most ingenuous strategies. Undoubtedly the single most important negative ingredient is the rise and spread of multi-drug resistant falciparum malaria that has its epicenter in Southeast Asia, from which it threatens the world in insidious fashion. Containment of this phenomenon has been the focus of attention for 30 years, more particularly the past decade, and represents the greatest challenge at this time in predicting the continuing impact of malaria globally on human history. So too does the compelling necessity to link malaria control with macro and micro economic planning. This challenge impinges on the sovereignty of individual nations in this region, for they exist in contiguity, so that successful applications of technology require collaborative political determination.