Community engagement is increasingly promoted to strengthen the ethics of medical research in low-income countries. One strategy is to use community advisory boards (CABs): semi-independent groups that can potentially safeguard the rights of study participants and help improve research. However, there is little published on the experience of operating and sustaining CABs. The Shoklo Malaria Research Unit (SMRU) has been conducting research and providing healthcare in a population of refugees, migrant workers, and displaced people on the Thai-Myanmar border for over 25 years. In 2009 SMRU facilitated the establishment of the Tak Province Community Ethics Advisory Board (T-CAB) in an effort to formally engage with the local communities both to obtain advice and to establish a participatory framework within which studies and the provision of health care can take place. In this paper, we draw on our experience of community engagement in this unique setting, and on our interactions with the past and present CAB members to critically reflect upon the CAB’s goals, structure and operations with a focus on the practicalities, what worked, what did not, and on its future directions.
Melioidosis, which is infection with the gram-negative bacterium Burkholderia pseudomallei, is an important cause of sepsis in east Asia and northern Australia. In northeastern Thailand, melioidosis accounts for 20% of all community-acquired septicaemias, and causes death in 40% of treated patients. B pseudomallei is an environmental saprophyte found in wet soils. It mostly infects adults with an underlying predisposing condition, mainly diabetes mellitus. Melioidosis is characterised by formation of abscesses, especially in the lungs, liver, spleen, skeletal muscle, and prostate. In a third of paediatric cases in southeast Asia, the disease presents as parotid abscess. In northern Australia, 4% of patients present with brain stem encephalitis. Ceftazidime is the treatment of choice for severe melioidosis, but response to high dose parenteral treatment is slow (median time to abatement of fever 9 days). Maintenance antibiotic treatment is with a four-drug regimen of chloramphenicol, doxycycline, and trimethoprim-sulfamethoxazole, or with amoxicillin-clavulanate in children and pregnant women. However, even with 20 weeks' antibiotic treatment, 10% of patients relapse. With improvements in health care and diagnostic microbiology in endemic areas of Asia, and increased travel, melioidosis will probably be recognised increasingly during the next decade.
The resurgence of malaria in the past two decades has stimulated a considerable amount of scientific and medical research. Understanding of pathophysiological mechanisms in malaria has advanced considerably in areas, such as the pathogenesis of metabolic dysfunction, the molecular processes involved in cytoadherence, and the causes of anaemia. However, in other areas progress has been slow. Much of the recent research has been conducted either with animal models or with cultured P. fakiparum parasites. The relevance of the observations, and the hypotheses they generate, to disease in man still needs to be established in many cases. The roles of cytoadherence, rosetting, and cytokine release have come to the fore, whereas the parts played by immune damage, intravascular coagulation, and increased vascular permeability have receded. Clinical investigation has taken some of the mystery out of malaria, but still relatively little is known for certain. The next challenge is to translate these advances in understanding of pathophysiology into improved treatments.
No abstract is provided for this article.
In areas of low malaria transmission, it is currently recommended that a single dose of primaquine (0.75 mg base/kg; 45 mg adult dose) be added to artemisinin combination treatment (ACT) in acute falciparum malaria to block malaria transmission. Review of studies of transmission-blocking activity based on the infectivity of patients or volunteers to anopheline mosquitoes, and of haemolytic toxicity in glucose 6-dehydrogenase (G6PD) deficient subjects, suggests that a lower primaquine dose (0.25 mg base/kg) would be safer and equally effective. This lower dose could be deployed together with ACTs without G6PD testing wherever use of a specific gametocytocide is indicated.
Drawing principally upon a rich vein of previously unexploited business records, this paper analyses the experience of British firms in Indonesia between the achievement of independence and the beginnings of the Suharto regime. As in The Netherlands East Indies, British enterprises occupied a significant position in post-colonial Indonesia in plantations, oil extraction, shipping, banking, the import-export trade, and manufacturing. After the nationalization of Dutch businesses from the end of 1957, Britain emerged as the leading investing power in the archipelago alongside the United States. However, during Indonesia's Confrontation with British-backed Malaysia (1963–1966), most UK-owned companies in the islands were subject to a series of torrid (albeit temporary) takeovers by the trade unions and subsequently various government authorities. Most of these investments were returned to British ownership under Suharto after 1967. But, in surviving the Sukarno era, British firms had endured 15 years of increasing inconvenience and insecurity trapped in a power struggle within Indonesia's perplexing plural polity (and particularly between the Communist Party and the military). Indeed, the Konfrontasi takeovers themselves, varying in intensity from region to region and from firm to firm, were indicative of deep fissures within Indonesian administration and politics. The unpredictable and unsettled political economy of post-colonial Indonesia meant that the balance of advantage lay not with transnational enterprise but with the host state and society.
