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Refugees, drug-resistance and guerrilla attacks: twenty years in the fight against malaria

When François Nosten set up a malaria research unit in his own home on the border of Thailand and Burma back in 1986, he could scarcely have anticipated how successful – and how dangerous – his work would prove to be.

Now, as the Shoklo Malaria Research Unit (SMRU) in Mae Sot, Thailand, celebrates its twentieth anniversary, Nosten, who was recently awarded a professorship by the University of Oxford, is able to reflect on the success of the unit, which is based amongst the region's refugee camps. The currently recommended malaria therapies (based on drug combinations including an artemisinin derivative) are the result of research carried out at SMRU, which is part of the Wellcome Trust's Major Overseas Programme in Thailand. Professor Nosten is amongst the top ten most-cited researchers in malaria research and has been a key player in the fight against drug-resistant strains of the parasite.

The Shoklo Malaria Research Unit, now part of -the Faculty of Tropical Medicine, Mahidol University, came into being when François met Nick White, then with the Wellcome Trust's Thailand programme (now Chairman of the SE Asia Overseas Programme in Thailand and Vietnam). White was looking for a field unit to study malaria. At the time, Nosten was a medical volunteer with the international humanitarian aid organization Médecins Sans Frontières.

"The original unit was very basic," explains Professor Nosten. "We set it up in my home, with a lab on the ground floor, complete with a centrifuge and one microscope for analysis of blood samples."

In 1989 the research unit moved to Shoklo, the largest of the refugee camps on the border of Thailand and Burma, where 9,000 Karen refugees from across the border were housed. The focus of the research was to study the efficacy of malaria drug treatments in pregnant women and in children.

The unit was forced to move to its current location in Mae Sot in 1996 one year after an attack by guerrillas from the Democratic Karen Buddhist Army, targeting foreign aid workers in an attempt to force the refugees to return to Burma. During the attack, Professor Nosten and his colleague Rose McGready had been forced to hide in the jungle.

Now, Professor Nosten is assisted in his work by Thai nationals from the region, including a number of local Karen and Burmese who received training by the SMRU team. In addition to studying malaria drug treatments for pregnant women, the unit has carried out crucial research into artemisinin combination therapies (ACTs) aimed at combating the rapid rise in drug-resistance. The unit has carried out the largest number of drug trials in malaria and research at the unit has been influential in changing WHO guidelines for malaria drug treatment.

"The work at Shoklo has been very successful, and together with NGOs and the Thai government, we have managed to reduce the incidence of infection by the most deadly form of malaria by over 90% in the camps and the surrounding regions," says Professor Nosten. However, he cautions, it will likely prove almost impossible to eradicate infections completely.

"At the treatment centres, we deal with a large number of migrant workers from Burma, crossing the border for work and returning to their families when they have finished," he explains. "If an infected worker crosses the border, they will bring with them the parasite, so perpetuating the cycle of transmission from humans to mosquitoes."

The reduction in the number of malaria cases has allowed the unit to focus on other health issues such as respiratory diseases. In addition, a surveillance network established in 1995 to monitor malaria infection in the camps along the border has now received funding to track the development of the avian influenza virus.

"We would like to congratulate François and his team," says Dr Mark Walport, Director of the Wellcome Trust. The Trust, along with Oxford University, has funded the SMRU since its inception. "Their work, often in difficult circumstances, has made a huge impact on the fight against malaria, not only in the region but also globally. François has shown dedication and a determination which is to be applauded."

The SMRU will be hosting a scientific seminar in Mae Sot on 28 December entitled "Twenty Years of Malaria Research: Outcomes and Perspectives" attended by internationally-renowned experts and featuring talks and debates on a variety of topics related to malaria, from epidemiology to therapeutics and from immunity to socio-economics.

Craig Brierley | alfa
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