Bad Medicine

Malaria has accompanied mankind on the slog through six millennia of ‘civilisation’. Hippocrates wrote about it in Ancient Greece; Alexander the Great is usually thought to have died from it (though some opt for assassination by poison) as are the Roman emperors Vespasian, Titus and Hadrian; Dea Febris, the goddess of fever, was worshipped in Rome: indeed, some historians have identified malaria as a major factor in Rome’s decline and fall. Malaria was also common in Medieval Europe until reduced by land reclamation, street lighting, ventilation and improved drainage; common in England among the fenlands and in the marshy ground of the Thames Valley, it claimed both James I and Oliver Cromwell. Theories about its origin have been legion: in the Middle Ages it was thought to be due to the action of planets and comets, to electrical storms or rains of ‘fever poison’; the Chinese thought it was caused by disharmony between Yin and Yang; while, for much of the 19th century, Victorian science was content to return to Hippocrates’s theory of an aetiology from ‘miasmata’ in swamps. Robert Desowitz recounts in some detail the discovery of the malaria pathogen transmitted to humans by the bite of the anopheline mosquito, and provides much fascinating information en route. Polynesia was malaria-free until Europeans brought the scourge in the drinking barrels of their sailing ships; the word malaria’, like ‘serendipity’, was first used by Horace Walpole, who wrote from Rome in 1740 of ‘a horrid thing that comes to Rome every summer and kills one’; dinosaurs are usually thought to have become extinct as a result of the Ice Age or the impact of a comet, but Desowitz speculates that the cause might have been kala-azar (visceral leishmaniasis), a near-relative of malaria, transmitted by the bite of the phlebotomine sandfly.

A specialist in tropical medicine, Desowitz is particularly concerned with the Third World, where 250 million people a year get malaria and 2.5 million die of it, and where women face a four hundred times greater risk of dying before or during childbirth than in the West, since pregnancy makes them especially vulnerable to malaria and other parasite-borne diseases. There are two main ways to combat malaria: via febrifugal drugs and vaccines, or by ‘supply-side’ prevention, which involves the extirpation or at least control of mosquitoes. The failure of the World Health Authority and the Agency for International Development to make significant progress on either front is at the heart of Desowitz’s depressing story.

In the years immediately after World War Two it was hoped that insect-borne diseases could be controlled by insecticides, especially DDT, which was sprayed on the walls of huts in the tropics. Alas, a new breed of insecticide-resistant mosquito came into being, as well as, according to Desowitz, ‘insect-resistant health authorities’ worried about the possible ecological damage from the over-use of DDT. By 1969 the medical bureaucrats were ready to throw in their hand. Mosquitoes developed enzymes to detoxify insecticides, they changed their behaviour, and the indiscriminate use of DDT by farmers accelerated the appearance of a population of resistant mosquitoes. Concurrently, the tropical medicine establishment failed to realise that some species of mosquito never came indoors and, even worse, that there were other species whose reproductive capacity was so great that no amount of DDT could ever cause an interruption of pathogen transmission: 50 per cent of the dreaded anopheles Gambiae would have to be killed off every single day of a five-year eradication programme if the WHO was to achieve its aim. There were also unintended consequences. In the Karen country in Burma the WHO team sprayed malaria-infected areas with DDT: cats, vulnerable to the insecticide though humans are not, died in droves; rats then multiplied and ate the villagers’ crops, driving them to the brink of famine.

As soon as resources were switched to finding an anti-malaria vaccine, disease levels rose steeply. The ancient remedy was ‘Jesuit bark’ or quinine, a staple of the African explorers, but this was replaced after World War Two by the alleged ‘miracle drug’, chloroquine. Chloroquine, however, was not cheap, and exhortations from the Third World asking for free supplies from the West fell on deaf ears. At the same time, in the years before the contraceptive pill, cynical voices were heard talking of the desirability of the malarial ‘cull’ (in plain language, the 30-40 per cent infant mortality rate) as a means of preventing a population explosion in Asia and Africa. All these arguments became academic when during the Sixties more and more strains of malaria became chloroquine-resistant. Since then no sustained efforts have been made to replace chloroquine. The reasons for this are complex: the motivations of profit and colonialism are defunct, and drug companies have largely dropped research into tropical medicine, not just because of the cost of investigation, development and trial, but because of the commitment needed to steer a new drug through the legal-bureaucratic labyrinth of bodies like the US Federal Drug Administration. The 2000-year-old Chinese drug Quinghaosu is the most favoured modern febrifuge, but the only really useful current idea is that of dipping mosquito nets in an insecticide called permethrin.

Desowitz’s summary of the results of the thirty years war against malaria makes depressing reading. Malaria is now more prevalent, less treatable and less controllable than in 1962, adults who were clinically immune have lost that protection, acute malaria leads to anaemia but blood transfusions in Africa now carry a high risk of Aids. The Dark Continent has particularly lost out from the failure of biotechnology, leaving Africans to wonder bitterly why the technical genius of the North has been able to make spectacular advances in the military sphere but not in that of tropical diseases. Nigeria has the same malaria rate as in 1934, and in retrospect the years between then and 1954, when there was ‘only’ a 40 per cent infant mortality rate, look like halcyon days. To add to the malaria-related ills of meningitis, tuberculosis, schistosomiasis and dysentery there is now Aids.

Apart from the unknown factor which has so far enabled the malaria pathogen to keep one step ahead of human ingenuity, Desowitz disentangles a number of human failings instrumental in the débâcle of the fight against the disease. The culture clash between North and South, Western technology and Third World mores and folkways, is salient to this. Desowitz indicts Third World health officials for clinging to the hope of a ‘quick fix’: a miracle malaria vaccine, a new DNA probe, a genetically altered mosquito. To some extent this fantasy is a result of earlier hopes raised and abruptly dashed. Asian and African countries which had devoted a third of their health budgets to the global anti-malaria campaign, in the confident expectation that the disease would be eradicated, gave up in despair when it was pointed out that the allegedly one-off infrastructure of men, vehicles and insecticides, which had been assembled for ‘one last push’ against the mosquito, would have to be continued indefinitely. Nor was their morale improved by the apparatchiks of the WHO, who excused themselves by saying that the anti-mosquito master plan had been fine: it was just the laziness and incompetence of the ‘natives’ that had ruined everything.

This idleness turns out, on closer inspection, to have been mainly a consequence of the failure of WHO and AID workers to communicate their intentions. Desowitz’s relish for black comedy is well catered for in the anecdotes he recounts. In Malaya, kampong dwellers accused the anti-malaria teams of making their roofs fall down by the use of DDT. Ensued incredulity, as Sir Richard Burton would say. The roofs were made of attap (palm fronds), and there was an attap-devouring caterpillar that dwelt in the roof. In normal conditions a parasitic wasp preyed on these pests and kept their numbers down, but the wasps were highly sensitive to DDT and the caterpillars were resistant. Consequently, when the malaria workers sprayed the kam-pongs, the wasps died, the caterpillars proliferated, and within a month all the roofs came crashing down. After that, unsurprisingly, malaria workers were no longer welcome.

Meanwhile, in India, in a village not far from Delhi, where poisonous snakes are loathed and feared, WHO scientists arrived one day without a word of explanation in a van bearing a serpent logo. They had discovered that cross-breeding male mosquitoes from Europe with Indian females produced sterile offspring: the hope was for euthanasia of the anopheles. Needless to say, the villagers were not let in on this vital piece of information and were perturbed to see votaries of the serpent releasing mosquitoes into the air. A village council was called to discuss the ‘bad medicine’, with the not entirely unpredictable result that the next time the van returned, the villagers put it to the torch.

These were merely the most spectacular examples of this failure to communicate. In 1966 the anti-malaria programme in the Philippines virtually collapsed when the locals refused to give finger-stick blood for analysis or to have their houses sprayed with insecticide, so confident were they that all this newfangled stuff about mosquitoes was nonsense. In Bangladesh Westerners confronted a grand slam of cultural barriers: the Malaria Eradication Programme was welcomed not for its putative benefits, but because it conferred salaries and status on local technicians; important material was held up or confiscated by customs; it proved impossible to get epidemiologists out into the field because they were teaching and practising privately to make ends meet, because the local directors refused to have their staff beyond peremptory recall and, principally, because in a Moslem country, where a man’s wife is in purdah, if an epidemiologist left for the jungle, there would be nobody to do the ‘marketing’. In India Western (especially US) scientists were unpopular because they were suspected of being CIA agents carrying out ‘Agent Orange’ style experiments – a suspicion later reinforced by the Bhopal catastrophe.

Desowitz reserves his chief criticisms, however, for the arrogance and corruption of the Western aid agencies. There had always been too great a gap between research and reality, between the intellectual world of biomedical research and the needs of the sick and those who nursed them. An older generation of field workers had been replaced with ‘“molecular types” more concerned with the exquisite challenges of modish science than with seeking practical problems.’ Moreover, the problem of the human ego bedevilled progress in the fight against disease. Desowitz tells how the Russian zoologist Elie Metchnikoff, the father of immunology, took microscope slides of malarial blood from Russia to show the German Robert Koch (the father of medical biology). Koch made Metchnikoff wait outside in the hall for over an hour, then cursorily examined the slides and declared that anyone who believed this was the malaria parasite was a Dumkopf.

Desowitz also accuses comfort-seeking WHO bureaucrats of having aroused unrealistic expectations in the Third World: if any field workers explained to the jet-setters from Geneva that control not extirpation was the only plausible goal, such ‘defeatists’ were written up in reports as ‘troublemakers’. But the most dreadful of all the Western high crimes and misdemeanors was the corruption of so many supposedly altruistic research workers. One scam involved the fraudster buying 200 owl monkeys at $475 each and 400 squirrel monkeys at $375 each (total $245,000), but billing the agency from his own dummy supply company at $630 and $525 respectively – a profit of $91,000. The man who worked that particular caper was sentenced to six months in a half-way house and fined $20,000 dollars. Meanwhile the Latin American suppliers of these monkeys were being paid kickbacks and sweeteners for getting supplies of the animals – which are an endangered species. Millions of dollars of ‘research’ money disappeared into the Swiss bank accounts of Colombian and Peruvian institute directors, all to provide monkeys to test a vaccine that could never work on humans anyway.

The arrogance, complacency and double-standardism of which Desowitz indicts the ‘lords of human kind’ in the North may be misguided: on one projection of the greenhouse effect, temperate climates will turn subtropical and the mosquito will be drawn into the British Isles with a future average temperature of 81.5 degrees F in London. Britain’s capital will in the foreseeable future be infested with the malaria for which there is still no general cure.