February 7, 2017

Photography Exhibition: Invisible Asia-Pacific Malaria

Invisible Asia-Pacific Malaria is a photography project on bringing light to Malaria in Asia Pacific. An exhibition on this project will be held from 2 to 29 September 2017 at the National Library Board, 100 Victoria Street S 188064, Singapore.

Commentary by Prof. J. Kevin Baird of the University of Oxford, United Kingdom and Eijkman Institute for Molecular Biology Jakarta, Indonesia.

Most of us think of malaria as an African problem. We tend to see malaria as a consequence or symptom of the poverty, geographic isolation, chronic conflicts, and poor economic development that hinders human progress on that continent more than on others. Malaria certainly thrives where impoverished people struggle for access to good healthcare, and malaria is indeed a very serious problem in Africa.

The Asia-Pacific sharply contrasts with Africa – booming economies, hundreds of millions lifted out of poverty, highly developed transportation and telecommunications links, and relative peace and stability. Among the 20 most powerful national economies (members of the influential G20) six are in the Asia-Pacific. Asian schools produce students representing nations that consistently occupy the top 5 ranks in abilities in mathematics, reading, and science. The Asia Pacific harvests extraordinary wealth by exceptionally well-educated populations. Surely, one may think, there is no place for malaria in such a dynamic and successful region, but malaria today in the Asia Pacific is pervasive, diverse, and invisible.

A Cambodian girl carries her brother across a cassava field at Pailin near the Thai border. The area around Pailin had been a Khmer Rouge redoubt for decades and appears to be the site of origin of artemisinin-resistant strains of Plasmodium falciparum, very likely derived from long-term use of it as monotherapy for malaria (now banned and aggressively enforced in Cambodia). The threat of untreatable falciparum malaria now looms in much of Cambodia, and also now occurs in Vietnam, Laos, Myanmar, and Thailand.

A Karen refugee mother bringing her infant for a check up at the Wang Phi Clinic operated by the Shoklo Malaria Research Unit. Endemic Plasmodium vivax malaria in this area is an important risk factor for poor maternal and neonatal health outcomes. Pregnant women and infants less than 6 months of age cannot be treated with primaquine against multiple relapses of vivax malaria, and vigilance against those attacks is required.

Despite the long march of extraordinary economic and political progress over the past half-century, malaria in the Asia-Pacific remains a very significant public health threat and burden. Over 2 billion Asians live at risk of endemic malaria, many tens of millions are infected (perhaps as many as several hundred million) each year and tens of thousands of those do not survive (perhaps as many as several hundred thousand). We cannot be sure of those numbers because the people who live with malaria in the Asia- Pacific are the least visible – the most isolated, poor, and voiceless. This exhibition of the photographic art of Pearl Gan is about them.

In 30 years of working on malaria in the Asia Pacific, I often requested of my local health authority hosts, “Let’s go where your malaria problem is the worst.” This became a familiar journey – paved road became gravel, gravel became dirt, dirt road became impassable. Malaria was its worst where people were isolated and hard to reach. It made their access to economic opportunity difficult, and access to healthcare even harder. This is where malaria lives in the Asia Pacific, the far-flung islands and villages beyond the pavement where people live quietly off our modern “grid” and endure the Asia Pacific malaria problem. The faces, lives, and suffering captured in Pearl’s images struck me as immediately familiar – Yes, these are the people of malaria that I know.

A volunteer malaria worker proudly displaying medicines used by the Battembang Team in Cambodia. The medical kit features a wide range of essentials such as the rapid diagnostics tests and other essential products that the volunteer malaria workers used.

Neang is a 40-year-old mother feeding her infant at a referral hospital in Pailin, Cambodia, near the Thai border. The child was considered severely ill and was admitted with a diagnosis of Plasmodium vivax malaria. This species is an especially difficult problem for pregnant/lactating women and infants because they cannot consume primaquine to kill dormant forms called hypnozoites that cause multiple renewed clinical attacks in the months following infection by a mosquito bite. Providers cope with the threat of relapse in these patients by a variety of means, none of which has been validated. The World Health Organisation offers no advice on this problem because there is no evidence to buttress any recommendation.

A young patient at the local Pailin Referral Hospital in Cambodia near the Myanmar border receiving a blood examination for malaria using a rapid diagnostic test (RDT) for malaria. These RDTs have become an essential tool in coping with endemic malaria.

Pearl traveled the backwaters of Asia Pacific, places just like where very many other Asians live – rural, isolated, and relatively impoverished. Her images shatter the caricature of the Asia Pacific of gleaming skyscrapers looming over huge modern cities teaming with over-achieving harried people engaged in industry, commerce and the broader world. We see people all of us can recognize as deeply human by the way Pearlcaptured them in work, play, warmth, and illness. Their rural environment and isolation, less familiar to us, limits their economic opportunities and access to healthcare. Endemic malaria stalks them, sickening and sometimes killing them. It is very hard for the rest of us to take notice of that because medical investigation and epidemiological reporting of illness and death in rural Asia-Pacific is rarely accomplished by thinly stretched or poorly developed public health services. This is invisibility – where malaria morbidity and mortality cannot be perceived and grounded in a knowable reality. Beginning to undo that is the point of Pearl’s art.

Photos copyright: Pearl Gan in association with Oxford University Clinical Research Unit, Eijkman Oxford Clinical Research Unit, Jakarta and The Wellcome Trust.