Social Science & Medicine 150 (2016) 144e152

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Social Science & Medicine

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Deviance and resistance: elimination in the greater

Chris Lyttleton

Anthropology Department, Macquarie University, Sydney, Australia article info abstract

Article history: Malaria elimination rather than control is increasingly globally endorsed, requiring new approaches Received 29 June 2015 wherein success is not measured by timely treatment of presenting cases but eradicating all presence of Received in revised form infection. This shift has gained urgency as resistance to artemisinin-combination therapies spreads in the 21 December 2015 Greater Mekong Sub-region (GMS) posing a threat to global health security. In the GMS, endemic malaria Accepted 21 December 2015 persists in forested border areas and elimination will require calibrated approaches to remove remaining Available online 23 December 2015 pockets of residual infection. A new public health strategy called ‘positive deviance’ is being used to improve health promotion and community outreach in some of these zones. However, outbreaks sparked Keywords: ‘ Malaria elimination by alternative understandings of appropriate behaviour expose the unpredictable nature of border ’ fi GMS borders malaria and dif culties eradication faces. Using a recent spike in infections allegedly linked to luxury timber trade in Thai borderlands, this article suggests that opportunities for market engagement can Rosewood cause people to see ‘deviance’ as a means to material advancement in ways that increase disease Global health security vulnerability. A malaria outbreak in Ubon Ratchathani was investigated during two-week field-visit in November 2014 as part of longer project researching border malaria in Thai provinces. Qualitative data were collected in four villages in Ubon's three most-affected districts. Discussions with villagers focused primarily on changing livelihoods, experience with malaria, and rosewood cutting. Informants included ten men and two women who had recently overnighted in the nearby . Data from health officials and villagers are used to frame Ubon's rise in malaria transmission within moral and behavioural re- sponses to expanding commodity supply-chains. The article argues that elimination strategies in the GMS must contend with volatile outbreaks among border populations wherein ‘infectiousness’ and ‘resistance’ are not simply pathogen characteristics but also behavioural dimensions born of insistent market aspirations. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction , , and SW ) (Kazadi, 2015). Unlike much of Sub-Saharan Africa, is a hyper- Moving from containment to elimination is increasingly endemic rather than holoendemic region for malaria infection. accepted as a necessary strategy to remove malaria's threat to Morbidity and mortality has improved markedly since the 1990s. global health security (Whitaker et al., 2014). To do so requires Average incidence across GMS dropped to 2.04/1000 by 2010 radical reconfiguration wherein success is not measured by timely (Hewitt et al., 2013: 54). As such, it is at a logical stage to target treatment of presenting cases but eradicating all presence of elimination (WHO, 2015). However, malaria shows tremendous infection (Williams et al., 2013: 3). Emerging artemisinin-resistant regional variation and regular outbreaks occur in forested border malaria in Southeast Asia has escalated urgency for this transition areas where poor accessibility and constant mobility hamper con- as potential spread to Africa raises grave concerns. Consequently, a trol efforts (Ciu et al., 2012). More than 120 million GMS residents 2025 deadline for elimination of falciparum malaria (and 2030 for remain at risk; in 2012 there were approximately 1.8 million ma- vivax) has been endorsed by national governments across the laria cases (58% Plasmodium falciparum) (Kazadi, 2015). In Thailand, Greater Mekong Sub-region (GMS - comprising Thailand, , incidence declined to 0.37/1000 by 2014 but pockets of endemicity persist, largely attributed to migration and mobility in border zones adjoining Myanmar, which bears the highest regional burden E-mail address: [email protected]. (Christophel et al., 2012; MOPH, 2011). In contrast, malaria in the http://dx.doi.org/10.1016/j.socscimed.2015.12.033 0277-9536/© 2015 Elsevier Ltd. All rights reserved. C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 145

Northeast Thai border province of Ubon Ratchathani was thought November 2014. Qualitative data collection took place in four vil- to be well-controlled with cases averaging less than 700 per year lages in Ubon's three most-affected districts - Buntharik, Nam Yeun over the past decade. But in 2014, infections jumped nine-fold as and Na Chaluai. Villages were selected with assistance from an NGO Ubon recorded the highest provincial caseload accounting for which implements Global Fund malaria prevention programs in nearly one-third of 24,100 infections nationwide. Ubon. Informants with a history of malaria infection were initially The dramatic rise is explained by provincial and national-level introduced to us by NGO staff (themselves local residents), who in health officials as being due to increased numbers of villagers turn connected us with other villagers. Qualitative interviews were overnighting in a national park adjoining Laos and Cambodia in jointly conducted by a Western medical anthropologist (fluent in search of endangered timber. The logic underlying this conclusion Thai and Lao) and a Thai researcher trained at CMU. Discussions is two-fold. In China, Siamese rosewood (Dalbergia cochinchinensis) covered past and present livelihoods, experience with malaria and currently fetches massive prices e one ornate bed carved from this programs to alleviate this, and rosewood cutting. Of those taking fragrant hardwood recently retailed for $1million in Shanghai (EIA, part in these conversations, ten men and two women had recently 2014: 2). Spurred by potential profits, poor villagers in Ubon risk overnighted in the forest. We also interviewed provincial and dis- injury, capture and disease to surreptitiously fell some of the re- trict health authorities, NGO staff, village health volunteers and gion's last remaining stocks. If correct, the inference that rosewood community members who do not go into the forest, and observed smuggling has driven Ubon's rise in infections foregrounds specific health promotion and mobile malaria screening activities in local challenges facing malaria's removal in the GMS: the volatility of communities. Data on regional policies and planning are informed outbreaks lies in inadequate preparedness for behavioural risk; the by author's part-time engagement by basis for unanticipated risk can be linked to larger distal forces; and between 2008 and 2014 as a technical advisor for GMS health and elimination strategies will require community engagement that infrastructure programs. Ethical approval was provided by Mac- addresses circumstances where avoiding infection is sidelined by quarie University. Pseudonyms have been used throughout. market-driven ambitions. Longer-term research into seasonal patterns, transmission in- The above factors are hardly new to malaria's history as a public tensities, disease burden, treatment adherence and outreach stra- health scourge, but they remain unresolved in a number of GMS tegies in the Ubon border zone would contribute valuable insights border zones. WHO recently suggested that malaria elimination in (Moss et al., 2015; Bourdier, 2016). In this article, I focus more the GMS needs “smarter and better organized programs to deal narrowly on connections between market ambitions, forest entry with migrants and mobile populations” coupled with concerted and malaria vulnerability. Open-ended conversations, coupled with attention “on the most remote static minority populations; though observations of village lifeways and health outreach activities, their numbers may be small, they are likely to be a critical residual provide an ethnographic basis for examining participation in source for malaria resurgence” (2014: 49). Villagers in Ubon are not rosewood extraction and risk behaviours this entails. Annotated minority groups per se, and there are relatively few migrants villager narratives are analysed within a framework that fore- compared to Myanmar border areas, but a significant number are grounds affective engagement with supply-chain capitalism. This mobile, marginalised labourers who join global timber supply- conceptual approach builds on author's long-term research into chains regardless of health or punitive consequences. health and social change in GMS border areas (Lyttleton, 2014) and Using data from Ubon Ratchathani (forthwith Ubon), this article frames risk within moral and behavioural responses to expanding addresses the need for close-hand studies within affected com- access to commodity markets. munities to understand context-specific malaria vulnerability Despite evidence of increase in malaria in Ubon and increase in (Stratton et al., 2008; Christophel et al., 2012; Durnez et al., 2013). It rosewood's bench-price, there are no empirical data to verify examines three related issues raised by Ubon's recent resurgence: smuggling as the causal factor behind the jump in infections, pri- First, the posited correlation between rosewood smuggling and marily because villagers avoid surveillance when in the forest. increased malaria in districts near the national park. In this context, Instead, we use qualitative data from Ubon public health officers the key variable is increased entry to the forest. Second, if the lure and village narratives to advance plausible connections. While they of specific commodity markets exacerbates malaria risks it follows remain hypothetical, foregrounding emic perspectives directs our that to lessen vulnerability successful prevention should consider attention to another level of analysis. Villagers embed cause and ‘infectious’ aspirations alongside parasite-based vector trans- effect of malaria infection in a larger framework than vector-driven mission. Finally, while multi-drug resistance is the priority concern transmission. In turn, these forms of local knowledge allow a (and, to a far lesser extent, mosquito behavioural resistance grounded examination of distal forces impacting on health condi- (Chareonviriyaphap et al., 2013), so too human ‘resistance’ becomes tions, motivations and decision-making that underpin the unpre- relevant when cautionary messages and vector-blocking mecha- dictability of malaria outbreaks. nisms are rendered less effective by more persuasive drawcards to material gain. Hence, global health security that intends to delimit 3. Border malaria (transnational) disease transmission, eradication that aims to address faltering pharmaceutical controls and health promotion Anticipated eradication of malaria is not new to the GMS, nor to that seeks to change behaviour must collectively contend with most of the malarial world. Even though malaria decreased abrupt examples, such as the Ubon case, thrown up by problematic dramatically during early years of Global Malaria Elimination Pro- articulations of modernisation and disease risk. gram (GMEP) in the 1950s and 60s, eradication was not so easily achieved. Parasite and mosquito resistance to chemical in- 2. Methods terventions became widespread and by mid-1970s malaria inci- dence worldwide was far greater than in early 1960s. Criticism In collaboration with Chiang Mai University (CMU), research reverberated around new iatrogenic forms: “In its well-meaning into migrant health and malaria vulnerability in Thai border prov- zeal to treat the world's malaria scourge, humanity had created a inces was conducted between August and December 2014. While new epidemic” (Garrett, 1995: 52). Control rather than eradication the larger study provides background to malaria transmission and became the more pragmatic option as by the 1990s malaria infected control strategies in the region, this article only discusses data from over 300 million people worldwide. Confidence has cautiously Ubon province which was collected during two-week field-visit in returned following substantial advances due to Millennium 146 C. Lyttleton / Social Science & Medicine 150 (2016) 144e152

Development Goals (MDGs). Globally incidence decreased by 29% 2014). Drug-resistant malaria in populations with high mobility and mortality reduced by 45% between 2000 and 2012 (Sluydts carries high risk of spread. If ACTs lose their effectiveness, global et al., 2014: 1). Such gains notwithstanding, malaria remains impact of multi-drug resistance has been estimated to include endemic in 100 countries (Williams et al., 2013: 2) and its persis- 150,000 additional deaths annually (WHO, 2014). Hence, with no tence in GMS borders highlights stubborn opposition to current new drug class yet available, major donors have rallied under interventions. Not unlike WHO teams who spent decades tracking WHO's Emergency Response to Artemisinin Resistance (ERAR). But, down last cases of smallpox, or those currently pursuing pockets of to date, programmes aiming to identify ‘hotzones’ and curtail polio in Afghanistan, eliminating GMS malaria will require detec- spread of resistance by monitoring treatment efficacy at sentinel tion and treatment sensitively attuned to these volatile foci of sites “have been small in scale and difficult to implement” (Smith transmission. Gueye et al., 2014: 2). Ongoing mobility, coupled with possibly Ubon lies surrounded by Tier 1 provinces where artemisinin- random mutation of parasites, makes containment fraught. Elimi- resistance has been detected (see Fig. 1). In Thai-Cambodia bor- nation is the logical answer: it negates the need for identifying sites derlands P. falciparum became resistant to chloroquine in late 1950s where resistance is or might appear “because transmission every- and subsequently sulphadoxine-pyrimethane and mefloquine. By where is reduced” (ibid). late 1970s, resistance had spread from Southeast Asia across South Specific populations most affected by border malaria in the GMS Asia ultimately causing millions of deaths in Sub-Saharan Africa. are those living in or near forest areas including ethnic minority Since 2001, artemisinin-combination therapies (ACTs) have become groups, mobile workers and people displaced by political upheaval the most effective first-line treatment for uncomplicated malaria. (Hewitt et al., 2013). The most efficient mosquito vectors are But in 2006 multi-drug resistant parasites were again identified, Anopheles dirus, requiring dense shade and high humidity, and first in the Thai-Cambodia borders (Noedl et al., 2008), and then in Anopheles minimus, found in and also in less shady fringes Southern Lao and Thai-Myanmar border regions (Ashley et al., and bamboo thickets associated with and plantations

Fig. 1. GMS sites of artemisinin-resistance (Source Kazadi, 2015). C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 147

(Hewitt et al., 2013). Control interventions throughout the GMS described that in previous years rosewood could be moved in stress accurate rapid diagnostic testing and referral (complicated by pickups along rural roads. Nowadays, it must be secreted through co-presence of P. falciparum and P. vivax), prompt, effective treat- the forest at night to a border crossing with Laos. While districts ment, and vector control measures emphasising consistent use of close to the forest have historically registered the bulk of provincial long-lasting insecticide-treated nets (LLNs) and indoor residual infections (Gaewphitun and Gaewphitun, 2009), more villagers spraying (IRS) (Suwonkerd et al., 2013). A. minimus and A. dirus are now overnight due to growing urgency to locate remaining rose- exophagic and exophilic (outside-biters and dwellers) lessening wood stocks, which locals estimate will last a year or two at most. effectiveness of indoor net use and household spraying (Durnez Villagers point to rosewood's impact readily seen in new houses et al., 2013); meanwhile outdoor transmission remains inade- and cars in villages near the forest. Local explanations of the link quately understood and addressed across the region (Ciu et al., between rosewood and malaria are given credence by expose's of 2012: 242). the luxury timber trade. Ubon is a case in point where scale and rapidity of outdoor transmission in 2014 was unexpected. It had not registered in the 4. Rosewood markets and malaria control top ten Thai provinces for malaria incidence over the preceding decade; annual caseload in Ubon was relatively steady, averaging In 2012, the UK-based Environmental Impact Agency noted 645 cases/year between 2003 and 2013 (see Fig. 2), and incidence “Thailand's rosewood loggers are incentivised by extremely lucra- hovered between 0.11 and 0.44/1000 for same period. But in 2014, tive prices offered by international traders for the prized wood e up incidence rose to 3.94/1000 and recorded infections totalled 7169 to US$6000 per cubic meter [equivalent to 1 tonne]”, and that (41% falciparum). Neighbouring Thai provinces bordering Cambodia illegal rosewood logging in Thailand boomed because “demand and Laos: Sisaket (770), Surin (241) Buriram (25), Amnat Charoen surged in China in 2007 and in the aftermath of Thailand's 2008 (2) showed much lower caseload in the same year. In other words, proposal to list rosewood on CITES being rejected by Laos and something particular was happening in Ubon. Cambodia” (EIA, 2012: 1). Rosewood belatedly became a protected Prior predictions of potential malaria outbreaks in Ubon ear- species throughout the GMS in 2013, but this has not removed its marked expansion of rubber (Petney et al., 2009) and new roads extraction; if anything it hastened it. Dalbergia cochinchinense has linking Laos, Cambodia and Thailand (Nigoon, 2013) as possible now largely disappeared from its native habitat in Cambodia, Laos, triggers. Yet, according to provincial malaria staff, Ubon's spike is and Vietnam. A recent EIA report cites studies conducted in 2012 not about deforestation, rubber expansion, improved surveillance, that show natural populations in Laos under severe threat with no or lack of access to resources, but because: “the market for rose- existing mature trees in surveyed provinces. It adds that in 2014, wood boomed in 2013e14 and we have no control over the number “traders were claiming there was no Siamese rosewood left in of villagers now going into the forest e it is probably in the thou- Vietnam. In Cambodia, mature trees are now considered rare sands.” Ninety five percent of 2014 infections were recorded in outside of strictly protected area”. Meanwhile in Thailand, “its three districts that adjoin the large Phu Chong Na Yoi national park presence is highly fragmented and mainly concentrated in pro- (686 km2). Ubon health officials suggest the primary cause of park tected areas in the country's lower northeast provinces, including entry is a combination of high price of ‘forest products’ coupled Ubon Ratchathani” (EIA, 2014: 3). with no fear of the law or malaria. In Bangkok, in mid-2014, senior Rosewood's demise is driven almost entirely by thriving in- officials at the Ministry of Public Health similarly explained that vestment in ornate reproductions of Qing- and Ming-dynasty Ubon's outbreak was due to expansion of ‘organised’ timber- furniture (hongmu) in China. In turn, increasing scarcity means smuggling and exacerbated by low local awareness and limited the price of Siamese rosewood, the most prized timber used in prior malaria experience (Manager Online 15/7/14). For their part, hongmu, has risen accordingly: “While trade has boomed, prices for villagers note the incentive to increasingly overnight in the forest the rarer hongmu species have also spiked - by March 2014, Siamese was spurred by government endorsement of rosewood as a pro- rosewood was retailing for RMB109,500 (US$17,633) per tonne, a tected species in 2013. Prior to this timber extraction from the 37 percent price increase compared to exactly a year earlier” (EIA, national park was reportedly less clandestine and the profits lower 2014: 2). In Ubon, dwindling stocks of the hardwood are found in as stocks still existed in neighbouring countries. Informants the montane semi-evergreen forests of Phu Chong national park. From there, cross-border syndicates smooth the hardwood's pas- sage to Vietnam and China through Laos where historically “cor- ruption, a lack of trained forest rangers, and the country's porous borders make it relatively easy to smuggle wood out of the country” (Mansfield, 2005: 285). Linkages between forest malaria and rosewood cutting, and its parallels to disease transmission in other extractive zones such as mines and logging sites (Suwonkerd et al., 2013), direct attention to the role of predictive strategies to remove drug-related resistance in the GMS. Recognising difficulties in pre-emptive control, WHO has conducted emergency response drills with health staff in border districts neighbouring Ubon. Prompted by spreading resis- tance in Tier 1 provinces (shown in Fig. 1), their focus is malaria outbreaks. But such trials are in a sense generic: they aim to buttress global health security, defined as “reduction in vulnera- bility of people around the world to new, acute or rapidly spreading risks to health, particularly those that threaten to cross interna- tional borders” (CDC, 2012: 5). Drug-resistant malaria fits precisely the type of imminent peril Fig. 2. Annual malaria infections in Ubon 2003e2014 (sources: Gaewphitun and Gaewphitun, 2009; Ubon provincial health department; Thai health promotion foun- global health security seeks to avert. If uncontrolled it is predicted dation www.healthinfo.in.th; and gis.biophics.org). to cost US$4 billion in the GMS alone, thereby motivating huge 148 C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 donor investment in eradication. Genomic modification of environmental or social interventions, ignores the context in which mosquitos and parasites is sometimes signalled as the ultimate particular trajectories of development process may conflict with solution (Vernick and Waters, 2004), but public health-based vec- health priorities including reduction of malaria risk” (Stratton et al., tor-control through bednets (LLNs) and insecticide spraying (IRS) in 2008: 855-6). affected communities remains paramount. In addition, to improve Poverty is widespread in Ubon and, insofar as malaria and and sustain effective outreach to vulnerable populations a new rosewood extraction are connected, the 2014 outbreak demon- behavioural intervention, ‘positive deviance’, is being enlisted. strates that development processes have, in fact, very close links to While not yet part of programs in Ubon it is currently utilised as disease transmission. Northeastern Thailand (Isan) remains the part of elimination strategies in border areas of Myanmar, Laos and poorest region with 17.37 percent of its population below the na- Cambodia. As such, it foregrounds the powerful but ambiguous role tional poverty line compared with 10.94 percent for Thailand both positive and negative moral adjudications can play in disease overall (2013 figures). Ubon ranks third poorest out of 20 Isan transmission and its behavioural control. Positive deviance high- provinces with 24.2 percent living below the poverty line (NESDB, lights non-normative but desirable health outcomes for otherwise 2015). In other words, villagers living in Ubon border districts ‘ordinary’ people within affected groups (Pascale et al., 2010). where malaria is most prevalent are amongst the poorest in Meanwhile, incautious and alternatively deviant behaviours stand Thailand. While this causes many Ubon villagers to out-migrate, as a major hurdle for health security programs which must accu- primarily to Bangkok, there has also been an influx of migrants rately engage (un)predictability (and sometimes transgressive as- from Laos dating back to the Vietnam War. Many border villages pects) of human behaviour in order to bring about freedom from have long-term residents still without documentation, further disease. As a case in point, throughout the GMS proliferating af- limiting income options. Across the border, Laos and Cambodia are fective economies e excitement at expanding commodity culture, significantly poorer at both national and local level (AEC, 2013). In anxiety over changing workplace relations, anger over land en- this context, clandestine timber cutting becomes a transitory live- croachments and so forth - are inseparably tied to material econ- lihood strategy for a significant number of disenfranchised vil- omies as massive infrastructure investments trigger heightened lagers. As in many historical circumstances, the fact that a large mobility and contagious aspirations for ‘the good life’ as an antidote number of them become malaria-infected indicates that volatility to poverty. There are very specific health consequences as the of disease spread can be linked to expanding commodity markets. combination of emotional appeals of modernisation and enduring From a contemporary vantage point, pre-emptive interventions structural disadvantage overshadows precautionary messages or that form part of an aspirational health security targeting world- timely health-seeking behaviour (Lyttleton, 2014). wide reduction of malaria to zero incidence must therefore confront dynamics that encourage a countervailing health ‘inse- 5. Poverty and vulnerability curity’. In this case, rather than the macro-parasite being off-shore landlords and wage-labour relations that drain more energy than Specific connections between malaria and material disadvan- the malarial parasite, as Brown (1987) famously argued, it is both tage are well-documented as low income countries bear a dispro- the lure and the predations of frontier supply-chains that make portionately high burden (Sachs and Malaney, 2002). However, Ubon villagers ideal hosts for increased malarial infection. optimal points of intervention are blurred by the fact that “lines of causation between poverty and malaria run both ways” (Packard, 6. Harvesting Siamese rosewood 2009: 75) and ‘conjunctures of vulnerability’ have ecological, temporal and socio-economic dimensions that collectively ratchet The bulk of rosewood sold in China is sourced “by teams of up consequences (Ribera and Hausmann-Muela 2011). Attempts to skilled men from rural villages who will spend weeks at a time in control malaria morbidity and mortality through prevention remote forests tracking down the last stands” (EIA, 2014: 4). Jaek (lessening exposure) or treatment (improving access) rather than replayed his recent trip to the Ubon forest as one of these ‘skilled targeting broader determinants of structural vulnerability are men’ for us: arguably a pragmatic response due to difficulties in creating radical He is in the hills. It is dark and silent. He and six others spread out reform. But, as Stratton et al. (2008: 855) warn, “given prevalent and stalk over haphazard foot trails in search of prized rosewood (Thai: poverty in most endemic regions such efforts will be less effective mai pha-yung). Trees up to seven metres tall can still be found but they in the long run in reducing total disease burden than approaches are increasingly rare. In late 2014, two metres of 10 cm thick rosewood aimed at underlying causes of differential vulnerability”. branch or trunk fetched 5000 Baht (roughly $166). Now even stumps of Despite the recognised role of distal determinants, previously cut trees are worth big baht (up to US$3000). If they find development-related causality is often not a priority within global wood, loggers can each make as much as US$1000 (30,000B) per trip. malaria control programs (Cueto, 2013). Brown et al., (2011: 255) They spend up to a week in the forest moving by night and resting by suggest comprehensive analysis of disease ecology should integrate day. The search for luxury timber is similar to wildlife poaching in that microbiological (biomedical), social and economic (public health) it requires clandestine pursuit and expert knowledge. Each rag-tag as well as political and ecological dimensions. But this synthesis is team (sometimes kin, usually buddies, occasionally husband and wife) seldom achieved in malaria programming: “global efforts to deal must have a leader who knows the forest, has links with traders on the with malaria have achieved limited success because malaria is Lao side and (hopefully) effective connections with local authorities increasingly being cast as a bureaucratic, managerial problem and that offer a degree of forewarning of ranger surveillance. To preserve the core of the problem systematically depoliticised” due to “heg- silence they use only previously stashed handsaws. If/when they find emonic global discourses on malaria that are increasingly rosewood, they cut it into two-three metre lengths and fashion a small becoming biomedicine-based technological fixes” (Kamat, 2013: xi- cart by strapping logs onto motorcycle wheels. Sometimes they cut xii). This tightened perspective emerged in sync with heightened new trails as they press forward to the Lao border. focus on MDG targets which, according to Vandemoortele (2011), Jaek is aware of his pounding heart as they push onwards lit by were sanitized to fit conventional development paradigms and small lamps on their caps knowing that, even with kick-backs, au- thereby excluded a broader human-centred perspective of sus- thorities are an ever-present threat. He is anxious, driven purely by tainable and equitable well-being. In this light, the “current focus intoxicating fantasies of a huge payout. They daren't talk to each other. on the basic science of malaria prevention, to the neglect of One person sometimes scouts ahead if they hear sounds. The trails are C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 149 littered with junk-food wrappers; items chosen for sugar and speed (less than 6 months e unregistered/illegal) in malaria reporting to with which they can be consumed. They scramble up steep, slippery isolate the more transitory human vectors as a means to allocate slopes: timber is heavy, carts cumbersome and bone-tired, they sweat resources and target activities (MOPH, 2011). District public health profusely - no breath for words, panting like a sports team e as they officials have a budget for village visits and mass screening. These push on to a long escarpment, the bottom edge of which marks Lao overlays intended to make vector-driven transmission legible and territory. predictable did not prevent the 2014 outbreak. Villagers who go to Other informants described how sometimes they almost fall the forest say they know of no-one pursuing rosewood who hasn't from exhaustion but for incessant pressure to ‘man’ up and not be had malaria. Officials we spoke with estimate close to 90% return seen as weak or they will never be asked to join another mission. infected. Significantly, those who go into the forest seldom attend This is not just gendered rhetoric. Provincial health data show that mass screenings organised by public health staff. Some villagers tell male-female differences in malaria infection in Ubon are 15:1. us they are scared to check: they fear any indication of infection will Frontiers are sometimes depicted as sites of potent conjuring acts mean only one thing to state medics ethat they are criminals who where “men and objects are contagious, recharging the landscape trade in contraband - and that they will therefore be reported to the with wildness and virility” (Tsing, 2005: 41). Similar infectious police. Furthermore, they worry that anyone under surveillance magic and demonstrable masculinity rule this border escarpment will not be asked to join upcoming foraging teams. Health officials where riches await those that muscle their way this far: wood turns suggest that this is paranoia on the part of villagers who see any into huge sums of money in ways unimaginable to Jaek and his civil servant as part of state control. Villagers and NGO staff say cohorts a year or two earlier. reality is different and police have harassed those whose fever Traders from the Lao side hide out in small caves along the becomes so intense as to make them seek medical help. escarpment awaiting their arrival. Jaek whistles a code signal when he gets close. Up to 20 traders each have designated drop-off spots along 7. Susceptibility, marginality and local deviance the cliff-edge. They scrutinise the catch and reward the exhausted lumberjacks. First item of exchange is amphetamines (yaba); traders Conventional strategies increasing use of LLINs and IRS have had hand these out in fistfuls, as both respite and enticement. Depending a major impact in village contexts, but they offer limited protection on their stamina and exuberance, villagers will sometimes undertake for those overnighting in the national park. This is recognised by another search. Already they have been there for three-four days, a Ubon health staff who began targeting outdoor transmission in second round means a week or more in the forest. Chance of capture or 2014, distributing insecticide-soaked clothing and forest nets/ injury escalates. Sometimes they muster collective energy; other times hammocks while acknowledging that behavioural compliance is a they pocket their gains and hightail for home. Once money changes significant challenge and, furthermore, health promotion needs to hands, logs are thrown over the cliff to pickups waiting below. address “psychological pressures” (jit wikrit) behind forest smug- Some Lao traders erect tents on the cliff-top as a welcoming haven gling. Earmarking desires and stresses of village life as necessary to foragers. They angle to establish loyal suppliers by offering solace intervention targets brings attention to broader dimensions of risk. after the gruelling search. As trade becomes more urgent given From this perspective, vulnerability to infection in Ubon is not just dwindling stock, enticements from traders have become more elabo- lodged in proximate behaviours or limited resources (although rate. Alcohol and drugs flow freely: cooked food for the first time in both are relevant) but emerges as a product of economic impera- days. Sex workers congregate, some seasoned in commercial sex, some tives and moral disjunctions born of entrenched poverty. The in- working other forms of enterprise (food and drink) who offer sex to crease in malaria cases in Ubon is significant not only because chosen partners as well. The workers relax for the first time in days in nearby forested borders are once again sources of drug resistance these liminal encampments. Relief is palpable: the wood is gone - they (fertile breeding area, high mobility, low degrees of immunity) but are no longer criminals. it also shows how low levels of infection can overnight become Injuries are common e falling logs, backsliding carts, misplaced hotbeds of transmission, and illustrates how ‘ruthless fantasies’ footing. So too arrests and sometimes violence when Cambodian prompted by consumer consciousness (Berlant, 2007: 278) can act smugglers, also ferreting out the prized wood, end up in shoot-outs as a trigger to diminished containment. with Thai rangers. Ubon villagers carry no guns: this is a trade-off In a control programme, the key objective is to reduce disease agreed with local authorities. In turn, they get the chance to flee. Not burden at a population level by building a ‘firewall’ around intense so cross-border Cambodians who are picked off regularly. Malaria transmission foci through prevention, testing and treatment. fevers are also common, either during or after the trade-runs. Elimination aims for zero incidence of locally contracted cases Mosquitoes are a trivial annoyance. Sleep comes at point of exhaus- including ongoing interventions to remove imported cases. Indeed tion, protection irrelevant. Sweat makes repellent useless and the some countries, such as Morocco and Turkmenistan, have achieved removal of cloying clothing exposes skin as ready target through the this status in recent years. But, so too, revamped eradication pro- toiling night; mosquito nets for hammocks are purely an encumbrance. grammes, such as the global ‘Roll-Back Malaria’ (RBM) initiated in Some burn leaves as a deterrent when they camp by small streams but 1998 have generated substantial critiques based, in part, on sub- it is not effective. Drugs and alcohol add to wilful avoidance of disease optimal implementation structures. For example, the Lancet prevention. Jaek notes that in the forest he thinks only of things he will noted “Five years on … it is clear that not only has RBM failed in its purchase to make him feel pleasure. aims but it may also have caused harm” (2005: 1439). Indeed, in Until they get home. Then, wives worry and men fret and talk with many areas of the world, comprehensive reductions have not been their comrades to see if anyone has a budding fever. If fever takes hold forthcoming. Stubborn low-transmission areas acting as reservoirs while in the forest it is immediately assumed all members of the team and persistent, underestimated presence of asymptomatic malaria are infected. Some weeks later, they will make another trip. combine to subvert successful control within the GMS and else- Since parasite resistance was found along these borders, in- where (White et al., 2014: 732). Inappropriate drug use including terventions have been ramped up and outreach campaigns have counterfeit drugs, artemisinin mono-therapies and substandard reached all local communities. With significant donor funding ACTs contribute to rising resistance. Mass drug administration border districts have village malaria posts and volunteers targeting (MDA) is now being trialled in some sites along the Thai-Myanmar both locals and mobile groups. Throughout Thailand, migrants are border. Historically, examples of community-level chloroquine classified as M1 (resident more than 6 months eregistered) or M2 treatment inadvertently triggered further resistance, and cognizant 150 C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 of potential pitfalls WHO has convened an evidence review group cooking meals to avoid mosquito bites” (Shafique and George, to assess current results of this approach (WHO, 2015: 107). In 2014: 5). In short, ‘deviance’ becomes something to aspire to in other instances, it is recognised that elimination strategies must, of the battle to eliminate malaria. necessity, involve deeper community engagement at a behavioural Non-normative but successful examples may well help highlight level, beginning with most affected marginalised populations and motivate other villagers to internalise malaria prevention (Smith and Whittaker, 2014: 1). Further challenging a shift to practices more intently. But there is more to malaria vulnerability elimination, and health security in general, is the fact that across than recalcitrant individuals in need of galvanising role models. the GMS movement is increasing, in particular in border zones How people perceive malaria risk and how this ranks against values where diverse populations are encouraged to interact within new inspired by spreading consumer consciousness is central. In social and physical landscapes. For marginal populations with little numerous circumstances neoliberal market expansion has multiple social or economic capital and little in the way of marketable skills, and contradictory impacts (Comaroff and Comaroff, 2001); in this livelihood change in these zones often involves accepting work and instance, village ‘entrepreneurs’ in Ubon are following the call of living conditions that pose threats to physical and mental well- fast money rather than heeding health warnings. Prevention dis- being as they form part of a growing global ‘precariat’. In border courses find little credence when balanced against social inequities areas, changing land-use practices and/or increased forest access as created by typical wage-labour conditions for these villagers natural resources become part of commodity chains create condi- (construction or rubber tapping). In this light, there is more to be tions suited to malaria transmission. said about deviance and localised moral adjudication. How devi- It is certainly no coincidence that malaria in the GMS is most ance is internalised as a form of motivation is the pressing issue. serious amongst migrants and other marginal populations (Nigoon, Kamon is a Lao migrant e he and his family crossed over into 2013; MOPH, 2011). The ready-made explanation is that mobile and Ubon seven years ago e they have five young children. We sit in the displaced people are more likely to encounter malarial mosquitos half-completed structure of their large new house, built in stages and have least resources to seek treatment, and furthermore “mi- with rosewood money. With no legal status, they cannot borrow grants are the cause of explosive epidemics amongst non-im- from any lending institution and must pay cash for everything. A munes” (Singhanetra-Renard, 1993: 1147). However, there remain neighbour's house has just installed large aluminium sliding doors. insufficient insights informing optimal avenues of assistance Other neighbours brought a Toyota Vigo. Kamon and his wife have (Christophel et al., 2012). In October 2014, led by Bill and Melinda no labour registration cards. He has worked as a transient labourer Gates Foundation (BMGF), major donors met in Myanmar stressing in Bangkok and in local rubber plantations making 200/300Baht that anti-malarial drug resistance in the GMS is an ‘emergency (US$7-9) per day. Nowadays in his village it is very hard to find situation’ that will require a regional elimination strategy and to anyone to harvest rice as wage-labour. The forest is preferred achieve this needs a ‘paradigm shift’ including flexibility, attention worksite where he can make 30,000Baht (approx. $1000) per trip. to local context and strengthened surveillance. Significantly, it Kamon's wife Jiap also joins him; “it is fun (muan)”, she smiles, “if concluded that “stakeholders will need a better understanding of we hear warning shots we just run”. Nor is malaria a deterrent: “we human movement throughout the region” (BMGF, 2014: 5). This can take treatment drugs so easily”. Having weathered malaria inadequately understood movement takes diverse forms and is several times, Jiap is far more concerned about ghosts of dead prompted, in part, by the shift from subsistence to wage-labour, Cambodian smugglers. For his part, Kamon wears a potent amulet particularly in border areas. Ubon rosewood cutters are not pre- around his neck that gives him portentous dreams - when to go or dominantly migrants but they offer a clear example of a transient not go to the forests: where to look for rosewood trees. mobile workforce made vulnerable to unanticipated health con- In the next district, Bamlung has Thai citizenship, although his sequences as economic corridors and frontier politics assist com- wife does not even though she arrived from Laos 15 years ago. modity capitalism infiltrate local communities. Bamlung is not at all cavalier about malaria. He has had it twice and While major donors host anti-malaria think-tanks, concrete fears his next bout will be fatal; he thinks it is his destiny and/or, exercises to engage affected populations also take place. In mid- more prosaically, because he didn't take medication properly. He 2014, the global NGO Malaria Consortium introduced an innova- notes it is easy to dispense with pills once one feels better. Bamlung tive strategy in Cambodia (also employed in Myanmar and Laos). thinks a lot about deviance, although not in terms used by health Noting that to move from control to elimination would require initiatives. He worries that karma (moral causality) might incur “more effective community engagement approaches to maintain future infection for anyone going after rosewood. On the other the participation and enthusiasm of communities in the wake of hand, he has experience advocating for stateless migrants in his disappearing disease” and “local and focused approaches are district and is well aware of structural underpinnings to margin- required to engage and target the high risk mobile and migrant ality. He knows rosewood plunder is against the law but also populations, ethnic groups and hotpops” (https://www.youtube.co regards normative moral frameworks as ambiguous: “why should m/watch?v¼iZd6qsG_myE). To do this Consortium proposed a new the desire to seek well-being for my family penalise me, when all (for malaria) approach called ‘positive deviance’. Championed by around rich people get richer through breaching legal and moral sociologists and increasingly used in applied health programs, codes?” He notes he is no less subject to the lure of modernity and positive deviance operates on the assumption that one can always desire to accumulate than anyone else - he uses the most obvious find local examples, albeit not the norm, that go against a stream of market opportunity available to him. Given that all villagers know negative outcomes (Pascale et al., 2010). In child nutrition programs the Chinese want this wood, they feel “it would be stupid not to go.” it is the family that manages to have well-nourished children Village life has, as Bamlung describes, changed profoundly as one despite suffering the same poverty as their neighbours; in HIV shifts (again) from labourer to forest forager. programs it is the sex worker who is able to make all her clients use All around there is evidence of financial windfall. Locals feel that condoms when her co-workers cannot. In this thinking, everyday neighbouring forests are their birthright. We have been using forest people can be enlisted into malaria work as advocates in order to resources for years although rosewood was seldom cut. It was pri- ‘change the world’. For example, a positive deviant might be “a marily kept for carved trays that hold the Buddha in both temples and female migrant worker, who never got malaria, always slept under houses and thereby a sacred wood. But perceptions have changed: now an insecticide treated net. In the evening, she always covered her it is a free-floating gift (larp loy) just for us. People spend the profits in arms and legs with a krama (local scarf) when watching TV or particular ways - villagers don't use rosewood money to pay off long- C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 151 term debts to agriculture banks (leveraged by policy-driven lending any of the above circumstances. Health security's contribution to over the past decades). Instead, they put down-payments on showy this ‘freedom’ is typically understood as ensured access to life- goods well beyond their means to pay off. New houses and new cars saving clinical and public health interventions. This is relevant in are commonplace when only a few years ago a second-hand motor- border zones (and some urban enclaves) throughout the GMS as cycle was all most could afford. Now, impractical shiny sedans bump access to timely treatment for migrant and other marginal pop- along potholed dirt roads as a status symbol. People without papers ulations (the ability to ‘track and cure’) is often compromised as use rosewood cash to pay for (expedited) citizenship claims. illegality, prejudice and/or cost prevents many from accessing state Responding to this lottery mentality, up to a thousand villagers tra- health services. But global health security must also anticipate verse the forest hurrying before the timber is gone. They would be situations when infectious ‘wants’ and the ‘freedoms’ they pre- irresponsible not to use this opportunity the market has offered. Sure! suppose themselves precipitate danger. Throughout the GMS, newcomers get caught, but more experienced villagers know what to neoliberal enticements spur the dreams of millions of migrants and do. Pay off headman, and other officials. If they do get caught they go to itinerant travellers in licit and illicit, conventional and unorthodox trial. Then they have to pay large fines. So they have to return to the ways as they seek opportunities not on offer in their home com- forest! Once rosewood is gone, we will turn to other hardwoods. This is munities. It is here that policies encouraging economic liberalisa- our life now. tion and those seeking to provide health security for ‘unruly’ border Vulnerability takes on more complex contours in this reading. populations collide. Unfortunately, it is also here that the voices of Bamlung and his fellows use what strategies they can in a climate of marginal populations are least likely to be heard. This eclipse pervasive market expansion. It prompts the question: How is shading life in border zones remains an obstacle to global health deviance best advocated as a buffer against infection when science and its ability to provide a life free from communicable disease, and law don't mesh with local moral adjudications? Care for family including malaria. and desire to be market players come first; precautionary messages To more effectively buttress human well-being against disparate (health or prohibition) lack persuasive weight. To villagers living in dimensions of ill-health, forms of risk analysis have attempted to one of the poorest parts of Thailand, rosewood is a gift to them and highlight the role values and power as well as trust and emotion their families. They see it as a birthright given that forests/frontiers play in decision-making (Zinn, 2010). While such approaches have next to their villages are outside capitalist enclosures in a formal figured more prominently in some disease control strategies, such sense. Rosewood is spiritually ‘special’ and only on offer to the poor as HIV prevention, they are less readily included in malaria cam- who have skills (finding, harvesting, portering) to undertake night- paigns where “currently technological weapons aimed at defeating time forest missions. These men feel they are, in fact, under moral the threat of the malaria parasite and mosquito appear to be uni- obligation to go for their family's sake even if it means becoming versally endorsed, while associated social, political and cultural part of a long history of frontier bandits. factors are downplayed, just as occurred with the overemphasis on Ironically, when WHO notes that “elimination of P. falciparum DDT in the 1950s” (Cueto, 2013: 60). Nor does a focus on positive malaria in the GMS must be seen as a public good that warrants deviance as an anti-malaria strategy, as valuable as it might be in sustained funding” (WHO, 2014: 10) it is thinking of bolstering terms of raising awareness, touch on values and power. Signifi- global health security rather than the quandary that Bamlung, Jaek cantly, in the focus on proximate behaviours, health promotion and their local compatriots face over the contribution of rosewood initiatives sidestep the emotional resonance of future-oriented to their own public good. Villagers we spoke to in Ubon don't see desire. In this light, attempts to bolster health security by control- the risk of malaria as an impediment. Desires for commodity con- ling infectious disease run the risk of being compromised unless sumption override anxiety over individual health. As such, they are they can also pre-empt wants-based susceptibility. Back in Ubon, not concerned about ostentatious wealth as evidence of illicit prevention campaigns confront the fact that to local villagers pursuits, unlike their blood which is undeniable ‘scientific’ proof of appropriating rosewood is a desirable form of deviance validated in transgression. They are reluctant to allow tests that might show more persuasive ways. As such, one wonders which might be the malaria or amphetaminese either a direct indication of wrong- best example of how ‘ordinary people can change the world’ as the doing. There is a fundamental misfit between local aspirations and health promotion catch-cry. Rosewood brings unheard of wealth state modes of control or NGO advocacy of deviance. It is in the gap that allows families a house, a car, legal status e in short, entry to a between village desires to be functioning players within global capitalised world and the opportunity to grasp an embodied economies, and thereby access the ‘good life’, and subverted dis- freedom from want. Hence, the basis for understanding vulnera- courses of health or legal regulations that malarial mosquitos bility, and from whence the next infection might come, takes us, in prosper. The social and cultural underpinnings of local decisions to Ubon at least, to the ambiguous designation of where transgression transgress, to be deviant, in the name of family security is missed in lies and how best to operationalise a purported entrepreneurial current endeavours to advance elimination-based health or human freedom as the mainstay of neoliberal sensibilities. security. Links between poverty, individual pursuits to counter this, In this light, conjunctures of vulnerability in the GMS are more and malaria are untouched. Initiatives to spread bednets and re- than limited access to health resources, coinciding impacts of sidual insecticide spraying of houses might control village trans- environmental and seasonal ecologies of risk and ramifying health mission but they do little to pre-empt forest infection: hammock burdens on household economies. They also emerge from regional nets and insecticide-laced clothes fall to the wayside in the rush to politics of migrant labour, frontier imaginaries and their insistent material gain. aspirations. Malaria elimination, and the health security it aims to instil, requires that parameters of outreach match dynamics of local 8. Conclusion vulnerability. In other words, eradication must engage the fine- grained details of malaria's volatility including contexts where Health security emerged as a clarion call to action in the late villagers place little value on cautionary practices as they repeat- 1990s at a time when providing human security became a promi- edly enter malarial zones and where science and law mesh nent concern for development institutions charged with protection awkwardly with local adjudications of the meaning of freedom. of vulnerable people against hunger, poverty, disease, and repres- Significantly, in instances such as the rosewood gold-rush, risk is sion. At its most prosaic, human security is imagined to provide a embedded in a decision matrix that privileges an ecology of supply- ‘freedom from want’ that constitutes deprivation or insecurity in chain consumerism. If predictions are correct that rosewood is 152 C. Lyttleton / Social Science & Medicine 150 (2016) 144e152 rapidly disappearing in the national park then infections will in all Garrett, L., 1995. The Coming Plague. Penguin Books, New York. likelihood decline as less villagers seek its harvest alongside Hewitt, S., et al., 2013. Malaria situation in the greater Mekong subregion. Southeast Asian J. Trop. Med. Public Health 44 (Suppl. 1), 46e72. increased donor-driven interventions prompted by the outbreak. Kamat, V., 2013. Silent Violence. University of Arizona Press, Tucson. Meanwhile, a salient lesson offered by Ubon's experience is that Kazadi, W., 2015. Strategy to move from accelerated burden reduction to malaria contours of local risk and construction of health security are readily elimination in the GMS by 2030. In: Presented at WHO 13th Stakeholder fi Meeting, Siem Reap, 24-26 Feb. obscured by shape-changing channels of market desire. Speci cs Lancet, 2005. Reversing the failures of roll back malaria, vol. 365. April 23. differ, but marginal populations face analogous threats in forested Lyttleton, C., 2014. Intimate Economies of Development: Mobility, Sexuality and border zones in many other parts of the GMS. “Smarter and better Health in Asia. Routledge, Oxon. ” ManagerOnline, 2014. Ubon's Malaria 8-times Greater than Previous Years Possibly programs (WHO, 2014:49) must attune proactive approaches to due to Timber-cutting Gangs. July 6. http://www.manager.co.th/Qol/ViewNe volatile risks linked to market engagement throughout GMS ws.aspx?NewsID¼9570000076027 (in Thai) (accessed 17/11/2015). border-zones in order to successfully remove residual outdoor Mansfield, S., 2005. Lao Hill tribes. Crit. Asian Stud. 37 (2), 277e288. MOPH., 2011. National Strategic Plan for Malaria Control and Elimination in transmission. Thailand, 2011 2016. Ministry of Public Health, Bangkok. Moss, W., et al., 2015. Malaria epidemiology and control within the international Acknowledgements centers of excellence for malaria research. Am. J. Trop. Med. Hyg. 93 (3), 5e15. Suppl. NESDB., 2015. Poverty Line by Province 2000-2013. Office of National Economic and My enduring gratitude goes to the villagers who generously Social Development Board. http://social.nesdb.go.th/SocialStat/StatReport_Fina shared their time to tell me of their lives and assist me understand l.aspx?reportid¼671&template¼2R1C&yeartype¼M&subcatid¼60 (accessed the health risks they face in malarial border zones. I am very 5/9/15). Nigoon, J., 2013. Migration and malaria. Southeast Asian J. Trop. Med. Public Health grateful to Professor Patcharanurak at Chiang Mai University and 44 (Suppl. 1), 166e200. members of Raks Thai malaria program for assistance in facilitating Noedl, H., et al., 2008. Evidence of artemisinin-resistant malaria in west Cambodia. e this research, and to Ubon Ratchathani Provincial and District N. Engl. J. Med. 359 (24), 2619 2620. Pascale, R., Sternin, J., Sternin, M., 2010. The Power of Positive Deviance. Harvard health staff for sharing data and providing valuable insights. Special Business Press, Boston. thanks to Sirichinda Thongchinda for collaborating in data collec- Packard, R., 2009. Roll back malaria, roll in development? Reassessing the economic tion. Research was supported by Macquarie University. Burden of malaria. Popul. Dev. Rev. 35 (1), 53e87. Petney, T., et al., 2009. Potential malaria re-emergence, northeastern Thailand. Emerg. Infect. Dis. 15 (8), 1330e1331. References Ribera, J., Hausmann-Muela, S., 2011. The straw that breaks the Camel's back: redirecting health-seeking behavior studies on malaria and vulnerability. Med. AEC., 2013. Data on Per Capita Income, the Proportion of Age, the Population of the Anthropol. Q. 25 (1), 103e121. AEC. ASEAN Economic Community. http://www.thai-aec.com/37. Sachs, J., Malaney, P., 2002. The economic and social burden of malaria. Nature 415. Ashley, E., et al., 2014. Spread of artemisinin resistance in plasmodium falciparum February 7. malaria. N. Engl. J. Med. 371, 411e423. July 31. Shafique, M., George, S., 2014. Positive Deviance: An Asset-based Approach to Berlant, L., 2007. Nearly Utopian, nearly normal: post-fordist affect in La Promesse Improve Malaria Outcomes. www.malariaconsortium.org/learningpapers. and Rosetta. Public Cult. 19, 273e301. Singhanetra-Renard, A., 1993. Malaria and mobility in Thailand. Soc. Sci. Med. 37 BMGF., 2014. Myanmar Malaria Partners: Summary of Key Themes and Action (9), 1147e1154. Points, 1e3 October. Naypyitaw, Myanmar. Sluydts, V., et al., 2014. Spatial clustering and risk factors of malaria infections in Bourdier, F., 2016. Health inequalities, public sector involvement and malaria con- Ratanakiri province, Cambodia. Malar. J. 13, 387. trol in Cambodia. Sojourn 31 (accepted June 3, 2015). Smith, C., Whittaker, M., 2014. Malaria elimination without stigmatization: a note of Brown, P., 1987. Microparasites and macroparasites. Cult. Anthropol. 2 (1), 155e171. caution about the use of terminology in elimination settings. Malar. J. 13, 377. Brown, P., Armelagos, G., Maes, K., 2011. Humans in a world of microbes. In: Smith Gueye, C., et al., 2014. The challenge of artemisinin resistance can only be met Singer, M., Erickson, P. (Eds.), Companion to Medical Anthropology. Blackwell by eliminating plasmodium falciparum malaria across the greater Mekong Publishing, Oxford, pp. 253e270. subregion. Malar. J. 13, 286. CDC., 2012. Global Disease Detection and Emergency Response Activities at CDC. Stratton, L., et al., 2008. The persistent problem of malaria: addressing the funda- Center for Disease Control, Atlanta. mental causes of a global killer. Soc. Sci. Med. 67, 854e862. Chareonviriyaphap, T., et al., 2013. Review of insecticide resistance and behavioural Suwonkerd, W., et al., 2013. Vector biology and malaria transmission in southeast avoidance of vectors of human diseases in Thailand. Parasites Vectors 6, 280. Asia. In: Manguin, S. (Ed.), Anopheles mosquitoes - New Insights into Malaria Christophel, E., et al., 2012. Joint Assessment of the Response to Artemisinin Vectors, pp. 273e325 (Intech). Resistance in the GMS. AusAID, Canberra. Tsing, A., 2005. Friction: An Ethnography of Global Connection. Princeton University Ciu, L., et al., 2012. Challenges and prospects for malaria elimination in the GMS. Press, New Jersey. Acta Trop. 121, 240e245. Vandemoortele, J., 2011. The MDG story: intention denied. Dev. Change 42 (1), 1e21. Comaroff, J., Comaroff, J., 2001. Millennial capitalism: first thought on a second Vernick, K., Waters, A., 2004. Genomics and malaria control. N. Engl. J. Med. 351, 18. coming. In: Comaroff, J., Comaroff, J. (Eds.), Millennial Capitalism and the Cul- White, N., et al., 2014. Malaria. Lancet 383. February 22. ture of Neoliberalism. Duke University Press, Durham, pp. 1e56. Whitaker, M., et al., 2014. Advocating for malaria elimination e learning from the Cueto, M., 2013. A return to the magic bullet: malaria and global health. In: Biehl, J., successes of other infectious disease elimination programmes. Malar. J. 13, 221. Petryna, A. (Eds.), When People Come First: Critical Studies in Global Health. WHO., 2014. Feasibility of Plasmodium Falciparum Elimination in the Greater Princeton University Press, Princeton, pp. 30e53. Mekong Subregion. In: Malaria Policy Advisory Committee Meeting Geneva, 11 Durnez, L., et al., 2013. Outdoor malaria transmission in forested villages of September. Cambodia. Malar. J. 12, 329. WHO., 2015. Malaria policy advisory committee to the WHO: conclusions and EIA., 2012. Rosewood Robbery: The Case to List Rosewood on CITES. Environmental recommendations of sixth biannual meeting (September 2014). Malar. J. 14, 107. Investigation Agency, London. Williams, H., et al., 2013. Discourse on malaria elimination: where do forcibly EIA., 2014. Routes of Extinction: The Corruption and Violence Destroying Siamese displaced persons fit in these discussions? Malar. J. 12, 121. Rosewood in the Mekong. Environmental Investigation Agency, London. Zinn, J., 2010. Biography, risk and uncertainty - is there common ground for bio- Gaewphitun, N., Gaewphitun, S., 2009. Malaria in Ubon Ratchathani province B.E. graphical research and risk research. Forum Qual. Soc. Res. 11. 2546-2550. Acad. J. Ubon Rajathanee Univ. 11 (3), 25e31 (in Thai).