The Making of a
Tropical Disease

A Short History of Malaria
Randall M. Packard
(Johns Hopkins)
The facts of malaria are simple and simply appalling: it infects 225,000,000 people, worldwide, annually. The mortality rate is 800,000 people a year ... mostly in sub-Saharan Africa where 90% of cases occur. It can be cured ... if you have the money and the medical help (Packard was infected in Mulanda, Uganda, but with professional treatment, is still with us).

At one time malaria could be held at bay with atabrine or chloroquinine, but that is now less a choice, as all the four varieties of Plasmodium are showing increasing resistance. The usual ways of protecting the poor --- and it is a disease of the poor --- include draining sources of standing water (buckets, jars, cans, pottery and, increasingly, abandoned automobile and truck tires) and a simple net hung over cribs and beds.

Under various government-sponsored efforts in Zambia and Uganda, ITNs (insecticide-treated bed nets) cost $5, an impossible price for the impossibly poor, but recently, through a subsidization program, they've been offered to the poverty-stricken for 60¢. Thus, for example, if we took 1% of the monies we spend each month in the border to chase off the Mexicans who merely want to work here and bought 1,000,000 mosquito nets and sent them to Africa we would probably save a gadzillion lives a month and the world might like us a little bit more, too.

§     §     §

Randall M. Packard is another of those well-meaning historians who is interested in informing us but, in the process, puts the reader into a narcoleptic twilight zone. I am quite a fan of books on the earth's scourges (disease, war, madness, greed, fundamentalist Baptists) but I insist on being entertained while I am being instructed, even on the most horrific details.

The facts of malaria are well known, interesting, and can be woven into a fascinating history if you are a Hans Zinsser or a J. W. Howarth. Unfortunately, if you are a Randall Packard, the story of malaria becomes a sloughing contest, sloughing the poor reader through countless, repetitive facts to get to a muddled, inconclusive ending.

It doesn't have to be so, and there are facts that manage, somehow, to escape the author's miasma. We know that malaria is caused by mosquito bites even though that is a misnomer. Mosquitoes don't bite you; they stab you; then they spit into your capillaries before sucking your blood; thus, the source of infections like malaria, yellow fever and dengue is mosquito spit.

As Packard rightly indicates, malaria is caused by poverty, poor sanitation, deforestation, overcrowding, and cows, horses, pigs, and goats (farm animals attract blood-sucking insects, which by feeding on them, causes more mosquitoes to appear). There are charts in The Making of a Tropical Disease that give some strange correlations. One graph pits the rate of malaria infection vs. foreign aid offered to Third World countries (p. 170). We might intuit that one: less aid, more disease.

More startling is the ratio between mortality and the price of cotton in the Mississippi Delta (p. 74). "While the conditions under which sharecroppers lived were generally poor, they became worse when cotton prices bottomed out."

    As the price of cotton fell, sharecroppers' ability to maintain their homes, feed their families, and acquire medicines when sick declined.

Even more tragically, when Americans get their dander up about local politics, deaths can rise exponentially. "Socialist tendencies by the Sri Lankan government led the United States to withdraw foreign aid from the country in 1963."

    At the time Sri Lanka had all but eradicated malaria, with 6 reported cases in the entire year. Over the next five years, malaria exploded upward, reaching 1 million cases by 1968.

We punished India the same way in 1972 for "entering into a friendship treaty with the Soviet Union. Malaria cases went from less than a million to seven million by 1976."

The author, like many scientists, has the unfortunate ability to rattle the common reader with sentences so abstruse as to be positively Martian: There are peoples in Western and Central Africa who have a resistance to P. vivax malaria, because "the blood stage merozites enter the red blood cells through a receptor on the surface of the cell known as the Duffy antigen. Expression of this antigen is determined by the presence or absence of two positive forms, or alleles, of the gene that controls this antigen. Most human populations possess two positive alleles for the Duffy antigen." By the end of this paragraph the reader finds that the plague of sleeping sickness has taken over the plague of malaria.

One can write elegantly even when dwelling on the most abstruse points of parasitology. Here's a quote from David McCullough that appeared in From The Path Between the Seas:

    Seen under the microscope, Stegomyia is a creature of striking beauty. Its general color is dark gray, but the thorax is marked with a silvery-white lyre-shaped pattern; the abdomen is banded with silvery-white stripes and the six-jointed legs are striped alternately with black and pure white. Among mosquitoes Stegomyia is the height of elegance.

"Stegomyia [he continues] is also, like the rat, a creature of human society. It survives by maintaining a close proximity to human beings. As among all mosquitoes it is only the female that bites --- that is, only the female feeds on blood, while the male gets by on other liquids such as fruit juices and is quite harmless. For the female, blood is essential to mature her eggs. Though the female Stegomyia can feed on any warm-blooded animal, her decided preference is for human blood, and thus the whole life cycle of the insect must be maintained in close association with human society."

McCullough writes nicely about the very stance of the mosquito, which was information enough for me to make part of my life, to observe, closely, nervously, exactly how those little bastards stand on my arm when they appear in my bedroom at nightfall, looking for supper:

    In contrast to the common northern mosquito, which stands with proboscis and head crooked at right angles to its body, Stegomyia and Anopheles kept proboscis, head, and body on a straight line, but at an angle to the resting surface. When feeding on an arm or wrist, an Anopheles looked as though it were standing on its head.

Finally, in the world of etymological literary excellence, let us recall Hans Zinsser's exquisite study of the life and death of a common louse in Rats, Lice, and History:

    The louse shares with us the misfortune of being prey to the typhus virus. If lice can dread, the nightmare of their lives is the fear of someday inhabiting an infected rat or human being. For the host may survive; but the ill-starred louse that sticks his haustellum through an infected skin, and imbibes the loathsome virus with his nourishment, is doomed beyond succor. In eight days, he sickens, in ten days he is in extremis, on the eleventh or twelfth his tiny body turns red with blood extravasated from his bowel, and he gives up his little ghost.

Zinsser concludes, "Man is too prone to look upon all nature through his egocentric eyes. To the louse, we are the dreaded emissaries of death. He leads a relatively harmless life --- the result of centuries of adaptations; then, out of the blue, an epidemic occurs; his host sickens, and the only world he has ever known becomes pestilential and deadly; and if, as a result of circumstances not under his control, his stricken body is transferred to another host whom he, in turn, infects. He does so without guile, from the uncontrollable need for nourishment, with death already in his own entrails. If only for his fellowship with us in suffering, he should command a degree of sympathetic consideration."

--- Carlos Amantea
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