 The drug resistance was first detected in Pailin province in western Cambodia
 In a small community in Western Cambodia, scientists are puzzling over why malaria parasites seem to be developing a resistance to drugs - and fearing the consequences. Ten days ago, Chhem Bunchhin, a teacher in Battambang Province, became ill with chills, fever, headache and vomiting. At a nearby health centre he was treated with drugs considered a "silver bullet" in the battle against falciparum malaria. This treatment with artesunate drugs was part of a clinical study being carried out by the US Armed Forces Research Institute of Medical Science (AFRIMS). In the past, artesunates have always cleared malaria parasites from the blood in two or three days. But after four days of monitored treatment, Chhem Bunchhin was still testing positive for parasites.
Dr Delia Bethell, an investigator working on the clinical trials, said he wasn't alone. Out of about 90 patients included in the study so far, roughly a third to half were still positive for malaria parasites after three days, some even after four or five days. "It appears that the artesunate is working more slowly than previously," she said. "It appears that the parasite probably is developing some kind of tolerance or is somehow less sensitive to the effects of the drug. But nobody knows why that might be." These early results need to be more thoroughly investigated, she said. The concern is that this could be the start of emerging resistance to the artemesinin family of drugs. If full-blown resistance did develop, it would be extremely dire. "This is by far the most effective drug we have," explained Dr Bethell. "And there are no new drugs coming through the system in the next few years." Scientists are particularly concerned because the last two generations of anti-malarial drugs were undermined by resistance.
And in those earlier cases, resistance also started in Western Cambodia, and in a similar way. No-one is sure why this area seems to have become a nursery for anti-malaria drug resistance. One factor could be the inappropriate use of drugs, related to a lack of medical supervision. The public health system is weak. Government clinics often run out of drugs or may be closed when patients want access to them. Instead, many patients visit private pharmacies to buy anti-malarial drugs there. Coloured tablets I visited one small drugs stall in Pailin's general market, sandwiched between a clothes outlet and a general grocery store. All pharmacies are supposed to be licensed. But the stallholder told me he didn't have a licence. He'd applied for one, he said, but the paperwork had never been processed. Many others running pharmacies, he said, were in the same position. I watched him and his wife make up their own packets of drugs on the glass-topped counter, shaking a variety of coloured tablets into unlabelled plastic bags. In many such private pharmacies, the customers choose what they want, deciding partly by price. The quality of the advice they get varies enormously. If, as a result, they end up taking the wrong drugs in the wrong combinations, this too can fuel drug resistance. The availability of many counterfeit drugs on the market only compounds the problem.
Professor Nick Day, director of the Mahidol-Oxford Tropical Medicine Research Unit, is also running clinical trials in the region. He and his team have also found that artesunate-type drugs are starting to become less effective. This resistance must be contained urgently, because its spread would be a global health disaster, he said. Resistance to previous malaria drugs caused major loss of life in Africa, he said. "If the same thing happens again, the spread of a resistant parasite from Asia to Africa, then that will have devastating consequences for malaria control." In a clearing in the jungle, about one and a half hours drive from Pailin along rough dirt roads, I watched health workers distribute mosquito nets to about 200 villagers. It's one of a series of measures being rushed through to stop the spread of resistant parasites. If they're not contained, history may repeat itself - and the fear is that many millions of people worldwide will lose their protection against this deadly disease. | ||||
SULTANWAS, Pakistan – When Pakistan's army drove the Taliban back from this small northwestern village, it also destroyed much of everything else here.
F-16 fighter jets, military helicopters, tanks and artillery reduced houses, mosques and shops to rubble, strewn with children's shoes, shattered TV sets and perfume bottles.
Commanders say the force was necessary in an operation they claim killed 80 militants. But returning residents do not believe this: Although a burned-out army tank at the entrance to Sultanwas indicates the Taliban fought back, villagers say most fighters fled into the mountains.
Beyond any doubt is their fury at authorities for wrecking their homes — the sort of backlash the army doesn't want as it tries to win the support of the people for its month-old offensive against the Taliban in Pakistan's northwest frontier region near the border with Afghanistan.
"The Taliban never hurt the poor people, but the government has destroyed everything," Sher Wali Khan told the first reporting team to reach the village of about 1,000 homes.
"They are treating us like the enemy," he said as he collected shredded copies of a Quran from the ruins of a mosque, one of three that were damaged, possibly beyond repair.
The anger in this village is an echo of recent years, when previous army offensives against the Taliban in the northwestern frontier area caused widespread civilian casualties and damage to homes. The military's heavy-handed approach here shows it may still be more equipped to fight conventional war with India than guerrilla warfare in the shadows of mountain villages and towns, where militants use civilians as cover.
The Associated Press traveled to Sultanwas on Wednesday after the Pakistani army briefly lifted a curfew in the Buner district to allow residents to return.
But the fight for the region is clearly not over. Just beyond the village, a makeshift army checkpoint shows where its control ends. Beyond that, the army and villagers say the Taliban are in charge, patrolling streets on foot and in pickup trucks.
The United States wants a resounding victory against insurgents who are threatening not only the stability of this nuclear-armed country, but also the success of the American-led mission in neighboring Afghanistan.
The army launched its operation in April to take back the northwest after the militants lost popular support across the region partly because of their defiance of a peace deal with the government. The Taliban have also carried out atrocities in the northwest and claimed responsibility for attacks that have killed hundreds of civilians elsewhere in Pakistan.
But residents of Sultanwas say the militants in their village threatened no one.
Khan, a 17-year-old who is quick with a smile and hopes to attend medical school, said about five militants occasionally came to a mosque. There, he said, they preached an ultraconservative brand of Islam and called for overthrowing the government because it was not implementing Islamic law. He said he did not agree with either position.
Khan fled with his family and most other residents when the army warned them last week to get out because the offensive was about to reach them.
The Taliban entered Buner last month from the Swat Valley, an advance that triggered the military's offensive. There was very little damage to buildings in the road leading to Sultanwas, which military officials said used to be one of the Taliban's major strongholds in the district.
The army says it is making every effort to avoid damaging buildings in the offensive. Reporters on a military-escorted trip to part of the Swat Valley last week saw no significant destruction.
But the army used helicopters, F-16 jets, tanks and artillery in the battle for Sultanwas. While the military says this tactic reduces army casualties by "softening up" areas before troops move in, critics question its effectiveness against a small and, for the most part, lightly armed insurgent force moving in and out of towns.
Khan and others insisted the militants were not living in their homes either before or after the attack.
There were no bodies, blood or obviously buried corpses in the rubble, which spans an area the size of two football fields, roughly a third of the village. A reporter could find no sign any rebels had dug in there or used the area as a base. Residents said the same.
"When the operation started, the Taliban all ran away from the area," said Rosi Khan, citing an account from the only three villagers who he said stayed behind. He could not say where those villagers are now.
Spokesman Maj. Gen. Athar Abbas said fleeing villagers had told military officials that militants were using Khan's house and others nearby. He said 80 insurgents were killed in the operation, and that other militants apparently removed their bodies.
But two officers involved in the Buner operations said most of the roughly 400 fighters believed to be there escaped to the mountains — terrain they know far better than do army troops trucked in from elsewhere in Pakistan. The two officers spoke on condition of anonymity because they were not authorized to give information to reporters.
It is a pattern the military says the outgunned and outnumbered militants are following elsewhere in the region, including in the main Swat Valley city of Mingora.
A defense attache for a Western embassy said the Swat operation appeared to be better organized and more coordinated than earlier ones in the northwest. But he questioned whether the 15,000 troops deployed against roughly 4,000 militants were enough to secure the region.
Besides Swat, Pakistan needs to keep troops elsewhere in the border region where al-Qaida and other militants are strong. But most of its roughly 700,000-member army is stationed on or close to the border with India, the country's traditional rival.
To claim victory, the government will have to ensure the militants do not return to the Swat Valley and Buner, and that the 2.4 million people who fled the fighting stay on the government's side when they come home.
The army is appealing for refugees to return to Sultanwas, but as elsewhere in Buner, few were heeding the call.
A week after the battle for this village ended, there was still no police, electricity or civilian administration.
"The political leadership is not here, there is no police," said a senior army officer, who asked not be named because he was not authorized to speak to the media. "How can you expect them to return?"
An AP photographer saw several people looting food and drinks from a damaged store in Sultanwas. They stopped only when other villagers reprimanded them.
At a checkpoint in Sultanwas, young men riding in buses from Taliban-controlled Pir Baba were ordered to lift their shirts and be searched, but there was little sign they were making serious checks of all those leaving the area.
In Pir Baba, Taliban fighters armed with rocket launchers and assault rifles are patrolling the streets, said Mohammed Yusuf, a 50-year-old farmer who was leaving but intended to return after buying vegetables at the nearest open market, several miles away.
"They are on the streets in the morning and evening," Yusuf said. "They are friendly. Some of them I know from my area."
