The Fever: How Malaria Has Ruled Humankind for 500,000 Years (22 page)

Still, the celebrated notion of Western benefaction of civilization, culture, and development upon the malarious African masses continued for decades. “The peoples of Africa south of the Sahara are still in an underdeveloped state so far as degree of civilization and culture,” noted WHO’s deputy director-general at a 1950 meeting on malaria in equatorial Africa. “With untiring generosity and an unflagging desire for progress,” he went on, the “very highly developed countries” would contribute their “cultural and scientific resources,” to alleviate Africa’s malarial burden.
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These attitudes derived from not just a different social experience of malaria and other diseases, of course, but also powerful political and economic interests. The British aimed to stamp out the African slave trade, which, besides being morally repugnant, posed an unwanted competitive threat to underemployed British workers.
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Britain wanted improved access to Africa’s natural resources, and hoped to establish political control, too. When the British denigrated Africans’ leaders, healers, and faith as chiefs, witch doctors, and devil worship, respectively, and touted Christian morals as the cure for a diseased continent, they had more than Africans’ spiritual uplift and public health in mind.

Today, the economic and political context in which Western philanthropists and aid organizations offer help to the malarious masses has changed dramatically. The West’s modern fight against African malaria is aimed not at undermining African governments but at collaborating with them. Our economies still rely upon Africa’s natural
resources, but our public health offerings are not based on speculative conjecture. Clinical trials have proven that antimalarial drugs, bed nets, and insecticides—unlike, say, the Ten Commandments—effectively alleviate malaria.

And yet, muffled echoes of that earlier dissonance reverberate. The Western clinicians staffing the malaria research ward in Blantyre don’t seriously consider what the Malawian women all around them think about any of the proceedings. They can’t. The mother of a patient in a mysterious coma, according to Taylor, thinks that the problem with the child is the horrible antituberculosis drugs he was given. The mother of a spaced-out and seriously ill girl thinks her daughter has a bad headache. The clinicians don’t make much of this. They do what they think their patients need, despite their charges’ palpable skepticism. Their achievement, in lives saved, is orders of magnitude greater than Livingstone’s—it took five years for his mission in southern Malawi to convert just a single African
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—and yet, the one-hundred-fifty-year-old gap between the world of the Western clinicians and that of the rural Africans they seek to help remains.

We want to think of Africans as battling an enemy, malaria, so that we can help them fight this enemy. We come—like Livingstone, with his moral righteousness—bearing the best our society has to offer: our riches and our technology. But the fight outsiders would like to wage against malaria isn’t always the same one fought by those who live with the disease.

In 2005, the international financing institution the Global Fund to Fight AIDS, Tuberculosis and Malaria agreed to provide $170 million to African governments to buy artemisinin combination drugs. Novartis had knocked down the price considerably and, expecting a flood of orders, kicked up production. By 2006, the company had manufactured thirty million treatments. But few African governments placed orders.
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“Everything is on the table!” exclaimed one frustrated Novartis rep. “Everything is there! The nets, the drugs, the money—but the orders aren’t coming in! I don’t know why!”
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In
the end, despite the available funding, African governments ordered less than half of Novartis’s supply,
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and the company had to destroy millions of the arduously produced tablets, for the heat-sensitive lifesaving drug wouldn’t keep for long. It was a “waste,” one malariologist said sadly, a “tragedy.”
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Everything about the Harvard Malaria Initiative, housed deep inside Harvard University’s School of Public Health, conveys a single, resounding message: this is where very important, very well-funded activities occur. The building is towering, majestic, especially in contrast with the narrow, rutted Boston streets that stream traffic around it. Security is thick. To broach the building’s cavernous underground parking center, your name has to be on a guest list. And to exit the garage, you have to take the elevator, whose green Up button will remain impassive until it receives a signal from a special ID you must swipe through a sensor. There’s more security upstairs, and more IDs, and more swiping of barcodes, to pass through heavy glass doors in order to reach the Harvard Malaria Initiative’s labyrinthine realm.

HMI is not just a center of malaria research, but an “epicenter” (as its website boasts), with funding support and corporate partnerships ranging from ExxonMobil to Genzyme. The floors gleam, the walls are lined with elegant blond-wood lockers and doors, and the labs buzz with purpose. Researchers here don’t need to budget, and in fact have no idea how much their work costs. “If we did the calculations, we’d probably all be flabbergasted,” one says.

The two dozen or so graduate students and researchers who work here meet weekly to share their results, in a conference room warmed by an Oriental rug and stately glass-doored bookcases. A buffet table offers them neatly trimmed sandwiches and fruit salad. The meeting’s presentations are graceful and articulate, laced with insider jokes about a Harvard education, and received by colleagues with thoughtful, imaginative questions. The only thing that seems to rattle them is the scrutiny of their mentor, Dyann Wirth, the gray-haired, forbidding molecular biologist who presides over HMI, who subjects them to slow, careful, monotone questioning. The day I was there, a few technical queries from Wirth pushed one young presenter over the edge. She misspoke, caught herself, paused, said something, retracted it, and then looked at her audience and laughed nervously.

This is a happy and well-fed gang, exuding optimism and ambition, the very picture of scientific leadership that Harvard self-consciously cultivates. No doubt each participant hopes to produce the kinds of data that will result in the uncorking of one of the champagne bottles poised at the top of one of the conference room bookcases.
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HMI, like a handful of other similarly well-endowed malaria labs scattered across the globe, may seem like the venerable product of centuries of unremitting investment in malaria research, the way that, say, the Human Genome Project or the National Cancer Institute can be seen as the results of long-term investments in research on technology and cancer. Surely, the relentless burden of malaria requires an equally relentless scientific response, and one of the top universities in one of the world’s wealthiest countries would, as a matter of course, devote a generous portion of its public health research to a global health priority of malaria’s magnitude.

Not so. Political and financial commitment to malaria research has been cyclical, sometimes spiking, often falling. Most of the malaria research centers I’ve visited look a lot more like the one at the Gorgas Institute in Panama, where malariologists toil in a cramped, dingy, and dimly lit corner of the building, mostly using
slides, microscopes, and some glassware, the same tools scientists have been using for over a hundred years. High-tech malaria research centers like HMI are not high points on an upward slanting line; they’re crests on a wave, leading a wake of deep troughs.

From its founding, malariology has been a fragile, wayward field, vulnerable to the enthusiasms and disregard of a fickle public. Overzealous researchers announce ballyhooed discoveries that turn out to be mistaken. Obscure, underfinanced scientists make breakthroughs that go all but ignored. Important insights, ones that could establish lasting and fruitful scientific paradigms for the field, are met with public skepticism, disinterest, or both.

Malariology’s founding question revolved around etiology. What precisely caused malaria? Folk wisdom held that swamps and miasmas were the culprit, but in the late nineteenth century, the new science of bacteriology emerged, exposing for the first time the tiny world of disease-causing microbes. In 1882, the German bacteriologist Robert Koch found the microbe responsible for tuberculosis, and in 1884, the microbe for cholera. In rapid succession over the coming years, scientists fingered the culprits for a range of pestilences: typhoid, tetanus, plague. Similarly, the thinking went, there must be some microbial pest responsible for the age-old scourge of malaria.
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Given the peculiar nature of malaria transmission, discerning the strange series of events leading to illness required interdisciplinary collaboration between naturalists, experimentalists, and clinicians. But an insecure scientific establishment, as status-conscious as a pack of wolves, made such collaborations difficult to sustain. Instead, prestige, resources, and influence flowed to the top dog, whether his story rang true or not. Not surprisingly, there were a few costly dead ends.

The economic impediment imposed by malaria couldn’t have been clearer to the leaders of the new republic of Italy, founded in
1871. The “Roman fever” shaped the making of the Italian state just as it had the fall of the empire. First,
Plasmodium
claimed the beloved wife of the nationalist revolutionary Giuseppe Garibaldi. According to the subsequent legend, Garibaldi carried her in his arms across the Roman Campagna as she died of malaria, an act of romantic heroism lovingly recaptured by writers and painters.
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Then malaria killed the first prime minister of the United Kingdom of Italy, just three months after the new state was declared. With 1,500 of 2,200 railroad workers in Sicily sick with malaria, 10,000 of the standing army of 180,000 in hospital with fever,
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and the new Italian state hemorrhaging millions of its strongest and most hardworking young men to the Americas, Italian railroads, mining companies, and philanthropists begged Italian scientists to find a solution to the problem.
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And so they did. One day in the late 1870s, two pathologists, Corrado Tommasi-Crudeli and Edwin Klebs, collected air and mud samples from the Roman Campagna. From the samples, they isolated ten-micromillimeter-long rods, which from the vantage point of their crude microscopes, seemed to develop into long threads. When injected into lab rabbits, the long threads soon had the bunnies heaving with chills and fever. Inside their slaughtered bodies, the pathologists found the ten-micromillimeter-long rods, once again.

The two scientists decided that they’d found the microbe responsible for malaria. It was a germ, it lived in the soil and the air, and they called it
Bacillus malariae.
They announced their findings in 1879.

The scientific method is not infallible, of course, and such mistakes are made, even when the entire economy of a newly formed nation depends on the results.

Counterevidence soon emerged.

In November 1880, Alphonse Laveran, a French surgeon stationed in Constantine, Algeria, peered at a crimson blob on a glass slide. How he found what he did is a bit of a mystery. Most nineteenth-century microscopists soaked their slides in chemicals, their cutting-edge
techniques thus unknowingly killing the malaria parasites in their samples and rendering them all but invisible amid the scattered debris of the magnified blood. Those who did examine blood from malaria victims while still fresh, as Laveran did, presumably did so more promptly than he did on this particular day. The blood was still warm when Laveran excused himself from its notice. What precisely he did upon abandoning his slide nobody knows, but whatever it was, it took about fifteen minutes. Maybe it was a cup of coffee.
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In any case, during the lull, the drop of malarial blood on the glass cooled. The change in temperature roused the parasites in the sample, which now considered that they had left the warm-blooded human for the cool environs of a mosquito body. Male forms of the parasite would soon be called upon to fertilize female ones, and each started to sprout long flagella and wave them about, in lascivious preparation. Laveran returned to his microscope expecting yet another static scene. Instead, the shocked surgeon caught sight of tiny spheres propelling themselves with fine, transparent filaments, wrigglingly alive.
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For the first time ever,
Plasmodium
had been spied by the human eye. Laveran found the creature again and again in his malarial patients, and watched it disappear from their blood after he administered quinine. He knew this was no bacillus, but something else entirely, and he would soon set out to show the world his new discovery,
Bacillus malariae
or no.
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Meanwhile, on the Mississippi River Delta, an American army surgeon named George Miller Sternberg attempted to replicate Klebs and Tomassi-Crudeli’s results with
Bacillus malariae
. He collected samples from a notoriously malarial area just as Klebs and Tommasi-Crudeli had done. Back in the lab, he isolated the tiny rods and injected them into rabbits. But the bunnies’ heaving fevers didn’t look like malaria to Sternberg. On a hunch, he decided to inject some other rabbits with an alternative substance to compare their fates. Given an ongoing debate on the infectious capacities of
spit, Sternberg decided to use his own saliva. He injected the spit into the bunnies, and it made them sick, too, in the same way as the tiny rods had. So now Sternberg knew that either malaria was caused by both the malaria germ
and his own slobber
or the erstwhile malarial germ did not exist.
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