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Panel 3. Health and Social Change in Southeast Asia

Chair: Xin Hui Chan (University of Oxford) xinhui@projectsoutheastasia.com

In the wake of rapid economic growth, Southeast Asia is undergoing a period of unprecedented social, demographic and environmental change.  The impact of these changes on health and disease has worldwide implications – the region is a global hot spot for the emergence of infectious diseases and leads the world in antimicrobial drug resistance.

This panel presents papers that propose strategies to address specific public health challenges posed by the pace and degree of social change in Southeast Asia. Topics include: antimicrobial stewardship, the role of integrative medicine, control of mosquito-borne diseases, water supply and sanitation, the impact of environmental degradation, disability and rehabilitation, and research ethics regulation, particularly in the management of infectious diseases.

The panel is designed to promote interdisciplinary and multi-sectorial dialogue on public health in Southeast Asia, and welcomes all who have an interest to attend.

Oral Presentations: Session 1

Paper 1: University of Oxford Tropical Medicine Network

Nick Day (University of Oxford) nicholas.day@ndm.ox.ac.uk

Paper 2: Tackling Antimicrobial Resistance in Vietnam

Arjun Chandna, Nguyen Van Kinh, Vu Dinh Phu, Pham Va Ca, Van Vinh Chau, Mattias Larsson, Ulf Rydell, Lennart Nilsson, Hakan Hanberger & Heiman Wertheim (Oxford University Clinical Research Unit, Vietnam) arjun.chandna@msd.ox.ac.uk

The 1986 Đổi Mới market reforms heralded rapid change for Vietnam and its healthcare system. Whilst contributing to better health outcomes, unregulated antibiotic access has brought an uninvited but not unexpected guest – antimicrobial resistance. Interventions to control antimicrobial resistance have been known for some time. However, implementation in emerging economies, where the need for effective antimicrobials is greatest, has thus far proved problematic. In Vietnam, where resistance rates are among the highest in Asia, the challenge is urgent and great.

A situation analysis performed by healthcare professionals, NGOs, policy makers, the Vietnamese Ministry of Health, and academic institutions such as the Oxford University Clinical Research Unit in Hanoi (under the auspices of the Global Antibiotic Resistance Partnership, GARP) highlighted that adequate legislation exists but a lack of resources prevents effective enforcement. In response to this we recently launched VINARES, a capacity-building initiative designed in consultation with local stakeholders to strengthen antimicrobial stewardship. It has been implemented at 16 hospitals across Vietnam. Through improved infection control, microbiological laboratory capacity, and concerted national surveillance, VINARES aims to bridge the gap between policy and action. The aim is to establish the surveillance structures required for self-sufficient antimicrobial stewardship in Vietnam for the long-term.

Paper 3: Responding to Mosquito-Borne Infectious Diseases in Southeast Asia: A Strategy of the City State of Singapore

Minako Jen Yoshikawa (Kyoto University, Japan) yoshikawa.minako.4r@kyoto-u.ac.jp

The significant population movements resulting from international travel and foreign labour flow facilitate the borderless transmission of emerging infectious diseases globally, which poses significant public health risks in highly populated urban areas. Urbanisation and tourism are both growing in Southeast Asia, and with these changes, the risk of transnational infectious diseases have also increased. By performing a combination of intensive fieldwork in situ and an in-depth review of previous studies from both the medical and social science disciplines, I investigated the situation of mosquito-borne viral infections and public health countermeasures in the Republic of Singapore, an international tropical city-state. Although highly developed, this regional business hub has to deal with the threats of Dengue virus and Chikungunya virus infections. Identifying both the medical and non-medical factors responsible for the spread of the infectious diseases in addition to the impact of outbreaks on the survivability of Singapore, this study explains the reason why the effective control of infectious diseases is even more critical for this young nation in Southeast Asia. The findings reveal a strategy involving multiple sectors of the government, private enterprises and people for the management of infectious diseases.

Paper 4: Existing and Assumed Boundaries of Healthy Spaces on the Basis of Urban-Rural Limits in the Vietnamese Mekong Delta: the Case of Diarrhoeal Disease

Panagiota Kotsila (University of Bonn, Germany) panagiota.kotsila@uni-bonn.de

Analysis of health prevention policies and discourse in Vietnam and specifically in the urbanizing region of the Delta reveals an underlying assumption that urban spaces are less prone to water-related health risks, such as diarrhoea. This is mainly based on the relatively widespread presence of water supply and sanitation (WSS) facilities within urban administrative boundaries. Comparisons of regional statistics on the prevalence of diarrhoeal diseases do not verify such an assumption. This paper illustrates that the factors shaping vulnerabilities with respect to these risks can be very similar in both rural and urban spaces. Furthermore, there is a wide variability of the types and the quality of WSS facilities within urban districts, just as much as within rural areas in the Delta. To explain such (health and WSS) differences one has to consider the nexus of other cross-cutting socio-cultural factors that go beyond boundaries of urban and rural characterizations. Such factors include the way people perceive interrelationships of water quality, food safety, hygienic behaviour and diarrhoeal risks, as well as the structural constraints that often limit their access to healthcare, WSS solutions and other prevention necessities. Emphasizing such aspects allows for a better understanding of what determines wide-spread epidemic diseases.

Oral Presentations: Session 2

Paper 1: Traditional Medicine in South East Asia

Gerry Bodeker (University of Oxford & Columbia University) gerry.bodeker@ndm.ox.ac.uk

Widely recognized as a cultural heritage of South East Asia and the first resort to healthcare by the poor of South East Asia, regional traditions of medicine are now the focus of a region-wide standard setting exercise. In 1956, Vietnam became the first country in SE Asia to formally include traditional medicine as a component of national healthcare. The most recent development has been passage of the Malaysian Traditional & Complementary Medicine Bill in December 2012. A number of international and regional initiatives have led to a coordinated ASEAN effort to regulate and standardize traditional medicine and herbal supplements. The ASEAN Free Trade Area, set for implementation in 2015 is the driver for this momentum.

The ASEAN Traditional Medicines and Health Supplements Product Working Group has been tasked with:

1. Implementation of harmonised technical requirements on product placements requirements, including safety, efficacy and stability guidelines and harmonised technical requirements on labeling requirements;

2. Creation of harmonised Good Manufacturing Practices requirements for traditional medicines and health supplements in ASEAN;

3. Development of an ASEAN Regulatory Framework on Traditional Medicines and Health Supplements; and

4. Transposition of the ASEAN Regulatory Framework into national laws of ASEAN Member States by 2014.

Much of this is industry led. Concerns have been raised that this model focuses on trade perspectives and in its efforts to standardize historically diverse traditions, may risk marginalizing or even outlawing long established folk practices such as local herbal medicine, traditional midwifery, therapeutic massage and traditional bone setting at the village level. In this context, the ASEAN initiative to regulate and standardize traditional medicine offers an important case study in the ongoing interface between tradition and modernity and the need to include local-level voices in policy processes impacting on South East Asian cultural heritage and healthcare.

Paper 2: Levels of Disability and Prosthetic-Orthotic (P&O) Needs in Indonesia: A Preliminary Report on Two Urban Communities

Peter Carey (University of Indonesia) peterbrcarey@hotmail.com

From 2008-12, Peter Carey served as Indonesian Country Director and Research & Development Director for the UK disability charity, The Cambodia Trust, which he co-founded in Oxford in 1989. During that time (2008-12), he established the Jakarta School of Prosthetics & Orthotics (JSPO) and carried out joint research projects with the Indonesian Ministry of Health in two urban communities to ascertain the incidence of disability and Prosthetic-Orthotic (P&O) needs in the wider Indonesian population.

Peter’s presentation to the Health Panel at the Oxford Project Southeast Asia Symposium will focus principally on the outcome of his second survey: a 126-household pilot survey of the Kelurahan (Sub-District) of Cilandak West (Cilandak Barat) in South Jakarta with a total population (May 2010 census) of 60,252 [33.421 male; 26.831 female) and 12.725 households. The survey took place over a two-month period in October-November 2011. By way of comparison Peter will also refer to an earlier survey carried out in the community of former Hansen’s Disease (Leprosy) patients who now reside in Karangsari village, Neglasari Sub-District, Tangerang, adjacent to Indonesian’s principal Hansen’s Disease Hospital, RSUK Dr Sitanala.

Paper 3: Research Ethics Committees (RECs) in Southeast Asia (SEA): What is Their Role?

Aimi Nadia Mohd Yusof (University of Oxford) aimi.yusof@st-hildas.ox.ac.uk

If RECs in developed countries have been continuously criticised in performing their role, we can be confident that there is more to learn about RECs in SEA. The globalisation of clinical trials has opened up opportunities for the SEA countries to stabilise and strengthen their economy. However, in the enthusiasm to provide an appealing setting to attract sponsors for clinical trials, sufficient ethical review by RECs may be compromised and can be made worse by the different application of their role among different RECs based on their preference. Some RECs may put their priority on human protection while some may believe that the benefit of research should be their main concern. It is still unclear what RECs are exactly for. The differences in understanding their main role may affect the decision making process among different RECs and thus may provoke criticisms from the public and researchers over the inconsistent decisions as a result of this. It is presumed that different RECs should have a uniform way of performing their responsibilities because researchers and their proposals should be treated equally if given to different RECs. This paper attempts to make clear the understanding of the role of RECs by using three different role models to ensure effective and efficient decision making among RECs. The decision to choose a model among these three requires careful analysis to avoid further confusion and hope to improve the way RECs work in SEA.

Poster Presentations

1.  Cost Recovery of Public Hospitals in East Java, Indonesia

Asri Maharani, Devi Femina & Gindo Tampubolon (University of Manchester)
devi.femina@postgrad.manchester.ac.uk