Comment

Southeast Asia: an emerging focus for global health

Published Online
January 25, 2011
DOI:10.1016/S01406736(10)61426-2
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The Venetians monopolised it, then the Portuguese

took control of it, and most European colonisers battled
ercely in the 17th and 18th centuries for nutmeg,
mace, and clovesonce grown only in the Spice Islands
of Indonesia, the worlds largest tropical archipelago.
Throughout its history, southeast Asia has witnessed
the rise and fall of cultures, empires, colonial powers,
and ideological regimes. Its natural environment
mirrors its tumultuous past. Life-giving monsoons, so
important for farming and sailing, also inundate and
wreak destruction in local cities each year. Volcanic
eruptions enrich and renew the topsoil, but also atten
scores of villages and bury vulnerable villagers. The
wet and hot jungles between the Tropics of Cancer
and Capricorn, friendly to infections and insurgents
alike, also sustain animal and plant life unequalled in
biodiversity. Life in all its compact, congested richness
is what distinguishes the region of southeast Asia
straddling the vast Asian geography between India to
the west and China to the north.
In many ways, southeast Asia is a microcosm of global
health, providing an impetus for this Lancet Series on
the health of the region. Although these countries
share many elements of history and culture, the region
teems with sociopolitical contrasts and contradictions.
Economic powerhouses and agrarian economies,
socialist and democratic regimes, and Muslim,
Buddhist, Hindu, and Christian faithsall of these lie
within the reach of a brief plane ride. This diversity

also plays out in contemporary health achievements:

life expectancy ranges from 56 years in Myanmar to
81 years in Singapore.1
Southeast Asia presents daunting health challenges.
Hosting complex animalhuman interactions, the
region has borne the brunt of several emerging and
re-emerging infections, testing the responsiveness of
local health authorities and the ability of the regional
and global communities to cooperate to control
diseases that cross national boundaries. Several strains
of multidrug-resistant microbes of global signicance have also emerged from the region. Recently,
artemisinin-resistant Plasmodium falciparum has been
identied on the ThailandCambodia border.2 Several
countries in the region have pioneered successful
HIV/AIDS control programmes.
From vast archipelagos to Himalayan foothills,
southeast Asias volatile geography and climate also
challenge the regions peoples and nations to respond
to natural disasters. The 2004 Asian tsunami that
devastated the coastlines of Thailand and Indonesia
and cyclone Nargis in Myanmar drew attention
to the regions vulnerabilities, but also stimulated
new models of disaster-management partnerships
between governments, multilateral agencies, and nongovernmental organisations.
Reminiscent of its heritage of maritime commerce,
southeast Asia is witnessing accelerating movements
in trade, especially of health services, marked by inux
of foreign patients and foreign direct investment in
hospitals. What is distinctive about the region, however,
is international health-related population movements.
Thailand attracts more than 15 million patients per
year for health tourism, with Singapore and Malaysia
a bit behind. The Philippines and Indonesia have an
aggressive policy of exporting health workers, especially
nurses, to generate foreign exchange.3,4 These trends
are likely to intensify as the ASEAN (Association of
Southeast Asian Nations) Framework Agreement on
Services comes into real action. Beyond health services,
southeast Asia has several major exporters of food and
agricultural products, with implications for global food
security and safety.
The number of migrants on the move in southeast
Asia has risen substantially in recent decades, reecting
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Comment

changes in the political and economic landscape.

Singapore, Malaysia, and Thailand have become a
magnet for migrants, both regular and irregular,
from neighbouring countries for employment. Health
problems can arise among irregular migrants who are
at risk for exploitation, poor living conditions, and
inadequate health care.
Health-systems developments in the region have
challenged existing regimes and stimulated much
debate. Reforms have led the Philippines and Indonesia
to devolve their health-care-delivery systems.
Thailands brave declaration on compulsory licensing
to produce and import essential medicines, and
Indonesias refusal to share samples of H5N1 inuenza
viruses with WHO, sparked major diplomatic debates
about balancing of national imperatives with global
interests.5,6 National experiments in expansion of
health equity and universal coveragePhilHealth in
the Philippines, Vietnams health fund for the poor, and
Thailands universal health-coverage schemeprovide
innovative models for equitable nancing that have
attracted global interest.7,8
Despite these shared challenges, southeast Asia as
yet lacks fully eective structures for regional health
cooperation. For historical reasons, WHO has split
southeast Asia into two regions, challenging regional
cohesion and coordination. ASEAN, the regional
cooperation alliance of ten nations, has not yet
accorded priority to health, although it has recently
intensied work in combating emerging infections
and responding to health emergencies. Southeast
Asias relative diversity is a source of both dynamism
and dissatisfaction as its less developed members seek
a common playing eld with richer neighbours. And
within the region, neighbours themselves can become
periodically embroiled in disputes, most recently along
the ThailandCambodia border. Internal political unrest
poses ongoing challenges as countries pursue varied
trajectories of democratisationseveral steps forward
in the case of Indonesia, backwards in Thailand,
and very little movement in Myanmar. Meanwhile,
political openings have created greater space for civil
society across the region, such as the doi moi reforms
in Vietnam and the active involvement of civil-society
organisations in the formulation and implementation
of various public policies in Thailand.

www.thelancet.com Vol 377 February 12, 2011

There can be no denial that much greater regional

cooperation would advance the health of people in
the region, through control of cross-border healthrelated ows, the sharing of health resources, and
prospects for joint action. That indeed is the premise
of this Lancet Series, which seeks to catalyse greater
regional solidarity in health. The people, economies,
and ecosystems of southeast Asia are indelibly linked
together. By bringing together an outstanding group
of southeast Asian researchers and health leaders,
this Series emphasises the centrality of research in
health-policy design and implementation, and the
need for investment in regional research capacity. This
Series underscores the imperative for more robust
and sustainable mechanisms for bringing academics,
professionals, and civil-society organisations together
with governments into more eective health and
public policy exchange for the advancement of health
of all people in the region.
Jose Acuin, *Rebecca Firestone, Thein Thein Htay,
Geok Lin Khor, Hasbullah Thabrany, Vonthanak Saphonn,
Suwit Wibulpolprasert
De la Salle Health Sciences Institute, Damarinas, Cavite, Philippines
(JA); China Medical Board, Cambridge, MA 02138, USA (RF);
Ministry of Health, Nay Pyi Taw, Myanmar (TTH); International
Medical University, Kuala Lumpur, Malaysia (GLK); School of Public
Health, University of Indonesia, Depok, Indonesia (HT); National
Institute of Public Health, Phnom Penh, Cambodia (VS); and
Ministry of Public Health, Nonthaburi, Thailand (SW)
rrestone@cmbfound.org
JA, TTH, GLK, HT, VS, and SW served on the steering committee for, and RF
contributed to coordination of, The Lancet Series on Health in southeast Asia.
We declare that we have no conicts of interest.
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3
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