The Fever: How Malaria Has Ruled Humankind for 500,000 Years (21 page)

Even the hardworking nurses in Queen Elizabeth’s malaria research ward, who spend their days tending to the torrent of malaria-plagued kids who flow through the ward, seemed to have little interest in the basic facts of malaria transmission. Gathered in a cramped lounge for afternoon tea in 2007, the nurses swung their legs over the edge of a twin bed covered in faded green blankets, which they used as a couch. They seemed bored by my questions in English, which made them go silent. Nevertheless, I asked them where the culprit,
Anopheles gambiae
, came from. After a long pause, one said, with some finality, “the swamp.” They all nodded. According to the
medical entomologist I later spoke to,
A. gambiae
specialize in Blantyre’s clear, sunny puddles.
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There’s a serious dearth of African clinicians specifically trained in malaria. Western donors have launched special programs to entice more Africans into the field, with scholarships and grants for study at Western universities. Trouble is, once they get the special training, they can get a job anywhere in the world. Few are willing to take the pay cut to go back to malaria territory. To entice foreign-trained Malawian clinicians to practice in Malawi, Queen Elizabeth Hospital must offer starting salaries that dwarf those of its most senior staff. It’s a high price to pay, yet still there are rarely enough clinicians to tend all of the hospital’s sick.

Most malaria deaths occur well outside the official medical system, so like a whale under the sea,
Plasmodium’
s true reach remains maddeningly elusive. WHO estimates that at least 60 percent of malaria cases in Africa, and 80 percent of malaria deaths, go unreported.
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Even under the watchful eyes of some of the most highly trained malariologists in the world, malaria rides under the radar. Such a common criminal, near ubiquitous, should be easy to diagnose, but it isn’t. The gold standard for diagnosing malaria is by microscopic examination of the blood. This takes time, training, and resources—and it is not easy. Technology that can diagnose malaria more simply has been developed, but it has yet to be widely disseminated. In the meantime, a trained technician must scrutinize a thick film of blood smeared across a slide, and because the parasite may lurk in just a few cells, the technician must hunt for it in one hundred different sections of the slide, adjusting the scope for each one. To pinpoint the parasite species, another, thinner smear of blood must be prepared, so that the microscopist can see the subtle morphological differences that distinguish
P. vivax
from
P. falciparum
from
P. ovale
.
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Since parasite levels vary over the course of an infection, this must be done several times over several days to accurately establish the fact of an
infection.
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And even this may not be sufficient to catch every infection. Using polymerase chain reaction (PCR), scientists can amplify and discern tiny fragments of parasite DNA. In one study in Senegal, two thirds of children whose blood, under microscopic scrutiny, appeared parasite-free were in fact harboring falciparum parasites as discerned by PCR.
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The other problem in collaring malaria is that the innocent look the same as the guilty: the blood of a healthy carrier of malaria parasites is indistinguishable from the blood of a mortally infected one. And so while microscopic diagnosis can show that someone
has
malaria parasites in his body, it can’t pinpoint whether that person is sick
from
malaria parasites. Indeed, there’s evidence to suggest that even the most experienced clinicians, using both clinical and microscopic diagnoses, mistakenly see malaria when some other pathogen is the true culprit. One out of four patients believed to have died of malaria in Terrie Taylor’s malaria ward turns out, upon autopsy, to have no malarial pathology capable of causing death. There are no infected cells sequestered in the brain. The patient had malaria, surely, but died of something else entirely.
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So how do clinics without the benefit of well-stocked labs, steady electricity, well-maintained equipment, or trained personnel—some don’t even have thermometers—figure out if someone has malaria? The simple answer is that they don’t. Given a widespread sense of malaria’s ubiquity, and the potentially grave consequences should a bona fide case of falciparum infection go untreated, standard procedure calls for “presumptive diagnosis.” That is, if there’s a fever, presume malaria and dole out the antimalarial tablets and shots.
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And so along with a high level of underreporting, there is a high level of overreporting. Nevertheless, statistics are duly gathered. In the mid-twentieth century, the malariologist Leonard Bruce-Chwatt estimated that roughly one million Africans die of malaria every year. Governments, international agencies, aid organizations, and the news media have basically stuck to that assessment. A team from Oxford University, using risk mapping and analyzing a compilation
of studies, reports, and unpublished records, estimated 1.1 million malaria deaths in Africa in 2000. In 2001, WHO estimated 1.1 million malaria deaths worldwide, with 970,000 malaria deaths in Africa.
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When, in 2008, WHO adjusted its assessment of malaria cases downward, slashing the figure in half, and reducing its estimate of malaria deaths by more than 20 percent, many experts simply shrugged their shoulders. They knew, as WHO said, that nothing had really changed on the ground. “It’s better fudging,” said one. But “it’s still assumption built on assumption built on assumption.” Even a “back-of-the-envelope calculation,” a prominent malaria epidemiologist added, would render more accurate numbers.
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The retired WHO scientist Socrates Litsios, a hunched, white-haired New Yorker, takes obvious pleasure in describing the antics of his solemn and ponderous former employer. He describes WHO’s statistical methods this way: Different WHO programs devote themselves to different diseases, from flu to tuberculosis to malaria. Jockeying for public interest, influence, and funding, and working in relative isolation, each tends to exaggerate the burden of its assigned disease. Finally, someone added up the mortality figures for all the diseases, which resulted in an impossible, implausible sum. Embarrassed, WHO held a meeting and literally doled out the numbers, Litsios says. Eyes gleaming, he imagines the scene: “Okay, measles, you get one million; malaria, you get a million; tuberculosis, a million.”
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He roars with delight.

For outsiders, of course, malaria is not some vague, mild, ignorable illness. It’s a killer disease, a scourge of the poor, a travesty in the modern world. That’s our outsider’s perspective, and we stick to it, disregarding, just as we have for centuries, the actual social experience of those who live with the disease.
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In the same way we’d dismiss the justifications of an alcoholic, we dismiss malaria patients’ apathy as a symptom of their disease.
After all, malarious communities are isolated—for malaria repels outsiders—and their chronic disease burden leaves them weakened and debilitated. The more malaria they have, the more remote and impoverished they become—and they adapt to this reality. They accept malaria, in other words, because malaria itself has lowered their expectations. That’s no reason for us, we figure, to do the same.
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We portray malaria in our media as a ferocious disease preying on powerless people. A photograph in
The New York Times
illustrating a story on a new antimalarial drug hatched in Western labs, for example, pictures a Mozambican boy lying on a rough wooden bench and gazing mournfully at the camera. The caption explains his obvious sorrow and lassitude by noting that the child has just learned he has malaria and that the disease kills three thousand African children a day. The boy, the reader is led to understand, has just received a death sentence. In fact, in endemic countries such as Mozambique, people get tested for malaria not because they are worried that they have it, but in the hopes that they do, for that would mean they don’t have anything worse. The positive malaria diagnosis the boy received would have been, in fact, a solace.
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We attribute the underlying conditions that create the social experience of malaria to a simple lack of money and the things it can buy. Malaria in Africa “is just a cash question, basically,” said Martin Hayman, a London lawyer and consultant for malaria-control organizations.
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Money buys better drugs, for example, so we ship the drugs to Africa, and the problem is solved. And yet, even if the quality of antimalarial drugs were to be improved from 85 percent to 100 percent, the overall effectiveness of malaria treatment could improve by only a single percentage point.
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That’s because, as two German epidemiologists found when they posted observers in local clinics and pharmacies, only 21 percent of people with malaria actually visit health centers. Of these, nearly 70 percent don’t have a sufficient history taken, and more than 30 percent don’t have their temperature taken. Twenty percent are prescribed the wrong drugs at the wrong doses. Ten percent don’t bother buying the drugs, and more than
30 percent don’t take the drugs as prescribed. The fact that the drugs are only 85 percent effective accounts for a very small portion of the failure in effective treatment. Even with 85 percent effective drugs, only 3 percent of local people were being effectively treated for malaria. If the drugs were 100 percent effective, the epidemiologists reckoned, the percentage of people effectively treated for malaria would rise only from 3 percent to 4 percent.
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We send reporters to the malaria-plagued to demand testimony on their need for Western rescue from the malarial wolf. I witnessed one such exchange, between a BBC reporter and a Cameroonian woman holding her deathly ill child. How would she pay for the hospital visit, the reporter demanded. It was an impossibly rude question, delivered sans preamble, but, both parties knew, it was critical for the central premise of the BBC story. The African mother must be captured on record describing her need for money. The woman’s face crumpled. The predicament she found herself in, of course, was much more complicated than cash. Whether she was about to cry or laugh was impossible to tell.

Our outsider’s perspective on malaria strikes those we seek to help as incomprehensible. Across the malarious world, medical anthropologist H. Kristian Heggenhougen writes, people profess “puzzlement over the focus on malaria.” People who live in poverty and who face myriad life-and-death issues wonder “why outsiders pay such attention and resources on what they see as a minor concern within the range of problems they face every day.”
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They “cannot understand why malaria should be selected for elimination,” says Thai social epidemiologist Wijitr Fungladda, “rather than their poor living conditions or any other disease.”
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(So what do they want?
The New York Times
’s Tina Rosenberg cites a survey that asked rural poor people just that. “The first three items,” Rosenberg notes, “were a radio, a bicycle and, heartbreakingly, a plastic bucket.”
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)

This is nothing new. For centuries, outsiders’ sense of malaria as a killer disease has collided with the actual social experience of those who live with it. When missionary doctor David Livingstone steamed
down the Shire River to Chikwawa in 1859, he came to help save the Africans from the “kingdom of darkness” in which they lived. Although his explorations in Central Africa were not explicitly for the purpose of disease alleviation—Livingstone hoped to “make an open path for commerce and Christianity”—the notion that Africa required such moral and economic uplift rested upon his conception of the continent as backward and diseased, under siege and in need of external rescue. Livingstone, like other Brits of the time, equated climate with health, and good health with good morals, which led him to believe that the heavy toll of African pathogens on British explorers indicated a malignancy in the land and moral turpitude in the people. They care for “no god except being bewitched,” Livingstone complained, and were “inured to bloodshed and murder.”
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By establishing missions across Central Africa, Livingstone would, he believed, light the interior and banish this moral darkness.

Livingstone’s long-term survival in Central Africa probably rested on the quinine therapy he pioneered, and the fact that he regularly used a mosquito net and wore heavy boots.
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(
Anopheles gambiae
are especially attracted to the smell of human feet.) But in keeping with the guiding principles of his work, he chalked it up to his own moral strength and respect for good clean living. “It is our conviction that we owe our escape from the disease . . . to the good diet provided for us by H.M. Government,” he wrote to
The Medical Times and Gazette
in 1859. He avoided “imprudent . . . exposure to the sun,” and partook of “regular and active exercise.”
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Livingstone’s project of enlightening Africa proved wildly popular throughout the English-speaking world. His book,
Missionary Travels and Researches in South Africa
, sold a staggering seventy thousand copies. He was the “hero of the hour,” enthused
Harper’s
magazine in 1857, “a man whose travels, adventures, and discoveries in the interior of Africa are only excelled by the heroism, philanthropy, and self-sacrifice which he has displayed.”
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But the central premise of Livingstone’s project, by his own experience, was deeply flawed. While nineteenth-century British society projected a dark, diseased continent in need of Christianity’s spiritual
uplift, Livingstone discovered instead that while African diseases regularly felled his European compatriots, the local peoples who joined his expeditions remained healthful.
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In Chikwawa, he found abundance and good health: luxuriant stands of cassava, beans, tobacco, pumpkins, okra, and millet tended by vigorously singing villagers. Chikwawa’s chief did not plead for help or make threatening or depraved gestures, but warmly welcomed the explorer. “We were not to be alarmed,” Livingstone remembers the chief telling him, “of the singing of his people.”
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