The Fever How Malaria Has Ruled Humankind for 500,000 Years

In recent years, malaria has emerged as a cause célèbre for voguish philanthropists. Bill Gates, Bono, and Laura Bush are only a few of the personalities who have lent their names'”and opened their pocketbooks'”in hopes of curing the disease. Still, in a time when every emergent disease inspires waves of panic, why arenrs"t we doing more to eradicate one of our oldest foes? And how does a parasitic disease that wers"ve known how to prevent for more than a century still infect 500 million people every year, killing nearly 1 million of them? In The Fever , the journalist Sonia Shah sets out to answer these questions, delivering a timely, inquisitive chronicle of the illness and its influence on human lives. Through the centuries, she finds, wers"ve invested our hopes in a panoply of drugs and technologies, and invariably those hopes have been dashed. From the settling of the New World to the construction of the Panama Canal, through wars and the advances of the Industrial Revolution, Shah tracks malariars"s jagged ascent and the tragedies in its wake, revealing a parasite every bit as persistent as the insects that carry it. With distinguished prose and original reporting from Panama, Malawi, Cameroon, India, and elsewhere, The Fever captures the curiously fascinating, devastating history of this long-standing thorn in the side of humanity.

Sonia Shah is an investigative journalist and the critically acclaimed author of The Body Hunters: Testing New Drugs on the World’s Poorest Patients and Crude: The Story of Oil. Her writing has appeared in The Washington Post, The Boston Globe, New Scientist, The Nation, and elsewhere.

The view through the mosquito net is blurry, but I can see the

thick skin of grime on the leading edge of each blade of the

ceiling fan as it slowly whirs around, keening alarmingly.

This is how it was every summer when I visited my grandmother’s

house in southern India. While my cousins snore on the bed mats

laid across the floor beside me, glistening bodies bathed in the warm

night breeze, my sleeping mat is ensconced in a hot, gauzy cage. The

mosquitoes descend from the darkened corners of the whitewashed

room and perch menacingly on the taut netting, ready to exploit any

fl icker of movement from their prey within. It is hard to fall asleep

knowing they are there, watching me, but eventually I drop off and

my tensed body uncurls. They sneak into the gaps my protruding

limbs create, and feast.

In the morning, all my hard work of trying to fi t in, to overcome

the Americanness of my suburban New England life, has been

undone, for my Indian cousins are smooth and brown while I am

speckled with bleeding scabs. My grandmother vigorously pats talcum

powder over my wounds, the white powder caking pink with

congealed blood, as my cousins snicker. I don’t understand how they

escape unscathed while I am tormented. But incomprehension is part

of the package of these childhood summers in India. Just outside my

grandmother’s house ragged families huddle in rubble along the road

and use the train tracks as their toilet. They wave their sticklike arms

in my face and moan woefully when we pass by on the way to temple,

caricatures of beggars. One boy’s leg has swollen to the size of a log,

and is gray and pimpled, from some disease brought on by a mosquito

bite. My grandmother tightens her grip on my hand. We give

the children nothing. I can’t understand this, either. When we get to

the white marble temple, it is full of incense and golden statues

encrusted with diamonds and rubies—to my seven-year-old mind,

the very picture of prosperity.

Part of me despises my estrangement, my incomprehension, the

fact that I must sleep under the suffocating net and take the malaria

pills while my cousins don’t. But part of me is secretly glad. The boy

with the swollen leg frightens me. The family who lives on the curb

frightens me. India frightens me. These fears, for the girl who is supposed

to be Indian but isn’t, are unspeakable.

When no one is looking, I crush the mosquitoes’ poised little

figures with my palm and smear the remains on a hidden seam in

the couch. Our Jain religion forbids violence of any kind. No eating

meat. No swatting flies. My grandmother wears a mask over her

mouth while she prays, to protect airborne microbes from inadvertent

annihilation in her inhalations, and considers walking on

blades of grass a sin. Meanwhile, there I am in the corner, cravenly

pulverizing mosquito corpses behind my back, blood literally on

my hands.

Back home in New England, the mosquitoes still bite, but there

are no nets at night, no pills to take, no scary beggars on the side of

the road. We shop for forgettable plastic trinkets at the mall. My fear

and loathing of the mosquito are blunted into games of tag. My father

calls himself Giant Mosquito, undulates his fingers like proboscises

and chases me and my sister. It’s scary, but fun-scary. We screech

with glee and stampede through the house.

• • •

Thirty years later, on the S-shaped land bridge between the North

and South American continents, I meet José Calzada. Calzada is a

mosquito stalker of sorts, and I, the mosquito hater, have come to

learn about the local mosquitoes and their exploits. A parasitologist

from Panama City, Panama, Calzada spends his time rushing to the

scene of disease outbreaks across the isthmus. The mosquito-borne

parasite that causes malaria, Plasmodium, is one of his specialties.

It is April 2006. For most of the past century, there hasn’t been

much work in this fi eld for people such as Calzada. Panama prides

itself on being one of just a handful of tropical developing countries

to have tamed its mosquitoes and nearly conquered malaria. American

military engineers built a canal through Panama in the early

1900s, and forced malaria to retreat to the remote fringes of the

country. Since then it has stagnated, primarily in its most benign

incarnation, vivax malaria, which is rarely fatal.

But things have changed in recent years, and Calzada has agreed

to show me some obscure signs. He emerges from the imposing

Gorgas Memorial Institute, Panama’s sole health research center.

Clean-shaven and trim, Calzada has a slightly worried look in his

eyes that is off set by high cheekbones suggesting a perpetual halfsmile.

I wait while he meticulously changes out of his work clothes—

button-down oxford shirt and slacks—and into a T-shirt and jeans.

Climbing into my diminutive white rental car and tossing a baseball

cap on top of his backpack in the backseat, he patiently directs me

out of the labyrinthine metropolis. Navigating Panama City’s congested

streets, past shiny skyscrapers and packed cafés, is a task that

challenges even my well-honed Boston driv ing skills.

After twenty minutes heading east out of the city, the road turns

quiet. It’s a lovely drive, with hills in the distance, verdant pasture

and scrub unbroken save for a few elaborately gated houses set far

back from the road. Colombian drug lords, Calzada says, by way of

explanation. Another hour passes, and the road rises, a glittering

lake coming into view, just visible through a tangle of jungle. As we

near the water, the pavement ends, and we pull over.

Here, at the end of the road, is the town of Chepo. From what I

can see, it consists of a wooden lean-to facing a sleepy roadside café.

Two police officers amble out of the lean-to, which turns out to be a

checkpoint. They take my passport and vanish, leaving Calzada and

me to buy a cold drink at the near-empty café. As we sit, I can just

make them out in the murk within the lean-to, inspecting the blue

passport with great care, turning it over and over in their hands as if

for clues to some baffling mystery.

Inspection completed, Calzada leads us on foot behind the road.

Th e hillside is green and lush, with a slick red clay track leading to

the crest. He heads up and I follow gingerly.

At the top of the hill lies an improb able settlement. Packed

together, not ten feet apart, are dozens of hand-built ranchos, their

thatched roofs sitting on top of roughly hewn wooden poles. More

arbor than hut, some of the structures rest on concrete slabs, with

airy wooden-slat walls on three sides, but most are fully open-air,

situated directly on the packed dirt. Inside the ranchos, smoldering

fi res are encircled by battered metal cooking vats, parrots sit on overturned

baskets, and hammocks sway from high rafters.

From the road, Chepo seems abandoned, but in fact, three hundred

of Panama’s indigenous Kuna people live here, tucked away.

It starts to rain, and we duck under the eaves of a rancho. Women

pass to and fro in bright puff ed-sleeve cotton blouses with patterned

molas tied around their waists and elaborate beaded anklets that

reach up to their calves. They are cutting plantains, carrying plump

naked children. One puts out a giant metal vat to collect the rainwater

sliding off the thatch. A rooster strides by purposefully.

A half-dozen boys clad in saggy cotton underwear and wearing

shell necklaces happily kick a defl ated green soccer ball. One boy,

around eight years old and wearing cracked red plastic flip-flops,

gnaws on a green mango pit while absentmindedly pulling on his

penis. A little girl walks by holding a baby covered in a rash, whom

she hands to me easily. It is a tranquil scene, earthy and ripe, this

hidden place at the end of the road.

It is soon apparent that most of the residents are in one of the

larger ranchos, sitting around a smoky fire. Peeking in, we see them

singing softly and dancing. A few are sprawled on the clay floor,

facedown, passed out. We’ve arrived in the midst of a fiesta, Calzada

whispers to me. A local girl has recently menstruated for the fi rst

time, and so the community has spent the day drinking chicha fuerte,

a brew made from fermented corn. As we watch, a woman and a

boy lift a comatose mud-caked man off the ground and drag him

home. Two women from inside the rancho follow them to the doorway,

smiling. Aside from a few furtive looks, they ignore us almost

entirely.

It wasn’t like this the year before, when Calzada first came here.

There is no En glish-language record of what happened to Chepo’s

Kuna community in 2005, save the one you are reading now. The

mosquitoes that hatched from Chepo’s stagnant puddles, the edges

of the lake below, in the open-water cisterns, had gone on a rampage.

Contaminated with the most malevolent malaria parasites known to

humankind in their spittle, they alit on the exposed and unclad Kuna

around them. By the time Calzada and his team arrived, nearly half

of the settlement was fevered, terrified, immobilized in their hammocks.

After days of triage, Calzada brought samples of the Kuna’s infected

blood back to his lab at the Gorgas Institute to analyze. The

most common malaria in this part of Panama is the relatively benign

vivax strain, caused by malarial parasites called Plasmodium vivax.

Instead, Calzada identifi ed parasites called Plasmodium falciparum,

which are more commonly found in sub-Saharan Africa. Worse, this

was no regular strain of P. falciparum, but a particularly nasty one

that had evolved re sis tance to standard antimalarial drugs, a trick the

parasites may have picked up somewhere in Southeast Asia. Malaria

experts around the world had been tracking the spread of this

bug for years. At Chepo, Calzada had discovered its northernmost

beachhead.

There was precious little evidence, when we first arrived in Chepo,

of the village’s connection to modern industrial life. In one rancho, I

saw a battery-powered radio, but other than that, we might have

been in the preindustrial world: there were no toilets, no running

water, no electricity. But then, as the rain steadily turned the dirt

lanes between the ranchos into mud, impromptu streams formed,

ferrying Chepo’s hidden debris to the lake: a blue plastic sandal, a

crushed orange juice container, a small gas can, and a shopping bag

came bobbing down the hill. We were, after all, less than two hours’

drive from a boisterous city of three million, a center of international

commerce through which passes 5 percent of the world’s trade. The

scene of malaria’s malevolent homecoming in this secluded settlement

cast its shadow over the very doorstep of the global economy.

The 2005 epidemic at Chepo did not occur in a vacuum. On the

contrary, between 1998 and 2004, malaria cases in Panama quadrupled.

2 And globally, malaria’s death toll has grown inexorably since

1981.

In 1995, Europe suff ered ninety thousand cases of malaria. Then,

in 1996, military troops in war-torn Afghanistan sparked a malaria

epidemic across Central Asia. Soon, Azerbaijan, Tajikistan, and Turkey

suff ered malaria outbreaks. By 2003, Plasmodium had preyed on

ten times more people in Central Asia than just a decade before,5 and

a tsunami of people carrying the parasite from Africa and Asia began

showing up in Europe. Today, eight times more malaria patients

arrive at clinics and hospitals across Europe than did in the 1970s,

and back then, most of the Plasmodium imported into Europe was of

the vivax strain. Now, nearly 70 percent is the deadly P. falciparum.

These days, mosquitoes infect between 250 million and 500 million

people with malaria every year, and close to 1 million perish.

Equally shocking is the sheer length of malaria’s tenure upon us.

Humans have suffered the disease for more than 500,000 years. And

not only does it still plague us, but it has also become even more

lethal. Th at’s quite a feat for a disease we’ve known how to prevent

and cure for more than a hundred years. During that same time,

we’ve vanquished any number of similarly once-commanding pathogens,

from smallpox to the plague, and have come to expect nearly

complete control over newer pathogens, such as SARS or avian fl u.

Th e few that slip through our fingers, such as HIV, are the rightful

subjects of anguish and soul-searching.

Yet despite the fact that we’ve known about malaria since ancient

times, and have the drugs, kill ing chemicals, and know-how to avoid it,

something about this disease still short-circuits our weaponry.

After dropping Calzada off, I headed back to my rental cottage along

the banks of the canal, where I spent the evening reviewing my notes.

Th e cottage was on stilts, and cooled by ceiling fans, but the window

screens were old and sagging, bent and giving way from the window

frame. Every morning in Panama I would awaken with some

unexpected swelling from the mosquitoes’ nighttime blood feasts:

under my eye, on my eyelid, on the palm of my hand. Smashed mosquitoes,

glued to the surface with their own internal juices, dotted

the walls.

A flimsy mosquito landed gently on my forearm. A familiar spike

of rage rose as I watched, incredulous, as the insect prepared to puncture

my skin with her proboscis. How dare she! Instinctively, my hand

snapped up.

Somewhere inside that cold-blooded, brittle body lurked entities

whose exertions explained the making of rich and poor, sick and

healthful. My hand came down a bit slower for the passing thought,

and I brushed the mosquito away like a crumb. Her delicate legs

snarled together, pitching the insect’s body forward at a steep angle.

Mangled, she skittered off my arm awkwardly as I watched, my vestigial

Jain sensibilities slightly horrifi ed. Finally she reached the precipice,

where she somehow took flight and vanished.