The Magazine

Marsh Fever

Now largely a tropical disease, malaria was once a global blight.

Aug 4, 2008, Vol. 13, No. 44 • By KEVIN R. KOSAR
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Mankind has won stunning battles against malaria. Worldwide deaths from malaria went from around 3.5 million per year in the 1930s to perhaps 1.25 million today. Brazil reduced its annual malaria cases more than 90 percent, from three million in the 1940s to fewer than 700,000 at the end of the 20th century. Many countries, in North America, Europe, and much of Asia, are malaria-free. The occasional case pops up in these nations--as it did in Palm Beach in 2003--but the disease fails to take hold and spread.

Malaria, as the title of Randall Packard's short, dense volume indicates, has become a tropical disease. Whereas it once ravaged areas as far north as New York City (killing 450 people in the same year that Edwards published his wrongheaded book) and Archangel, Russia, malaria is now limited to Central America, Southeast Asia, and Africa.

These successes, combined with the ugly havoc that malaria continues to wreak, may have helped spur the recent calls for renewing the battle against malaria. The World Health Organization launched its "Roll Back Malaria" initiative in 1998, and this past year the Gates Foundation announced its intention to spend billions of dollars to eradicate malaria worldwide.

But should we expect past performance to be indicative of future returns? On this question, The Making of a Tropical Disease is especially pertinent. Packard, who directs the Institute for the History of Medicine at Johns Hopkins, has not produced a history of malaria per se. Regrettably, the reader will not find a chronological narrative that starts with the ancient Vedic and Chinese writings on malaria, or one that recounts in detail malaria epidemics and their effects on war, peace, and the rise and fall of nations.

Rather, Packard yanks the reader into an ongoing public health debate. He piles up case studies to argue that

The history of malaria has been driven by the interplay of social, biological, and environmental forces. The shifting alignment of these forces has largely determined the social and geographic distribution of the disease. .  .  . By contrast, efforts to control malaria .  .  . have been driven by a narrower vision of the disease and its causes that has privileged biological processes and focused on attacking anopheline mosquitoes and malaria parasites.

The result is a short book that reads long and tries the commitment of the general reader. That said, Packard's big point is a critical one. Malaria reduction and eradication have tended to be most successful in countries that were well on their way to being First World nation-states. The reasons for this are not hard to see. Modern nation-states have the wealth, power, and administrative competence to take the steps required to stop malaria. In the 1930s, the Tennessee Valley Authority used federal money and might to wipe out malaria: Marshes were drained, screens were installed in the windows of homes, medical facilities were established, DDT was sprayed, and the public was schooled on the causes and prevention of malaria. Malaria vanished in less than 20 years. (Around the same time, Italy similarly vanquished its infamously Anopheles-stricken Pontine Marshes.)

The results of this disparity are not hard to see, either. Today, if someone in, say, San Diego is suffering from chills and fever, he probably will head by car or ambulance to the nearest hospital where he'll immediately be diagnosed by trained medical personnel, given the correct drugs, kept in quarantine, and brought back to full health in short order.

In Zambia or Angola, today's malaria victim might be taken to a witch doctor who blames djinni and provides treatment that is useless at best. Or the afflicted might be carried for a few days to the nearest understaffed medical clinic, where he may be given watered-down medicines that kill the weakest plasmodia while leaving the strongest, most resistant, bacteria to propagate further. During his journey to and from the clinic, the victim may be bitten by more mosquitoes that will, in due course, spread the disease to others. Once home, the mosquito net provided by the clinic might end up being rigged up in a stream to catch fish rather than hung over his bed.

If that is not enough of an impediment to future progress in curbing malaria cases, there is also the matter of the plague itself. Initially, as Packard shows, mankind was able to score many fast victories against malaria because its attacks on the mosquito and the plasmodium were novel. With the passage of time, both organisms have responded to the assault, developing resistance to some medications and insecticides. There are at least 30 different malaria-carrying species of the Anopheles mosquito, each of which is evolving defenses.