There is a disease that annually sickens over one-half billion people, killing over 1 million. Because of climate change, increasingly aggressive resource extraction, and growing multi-drug resistance, every year, the disease fells 16 percent more than it did the year before. By the turn of the century, this disease will be the world’s most deadly contagion.
It isn’t Ebola, or SARS, or avian influenza. It isn’t multi-drug-resistant staphylococcus bacteria. It isn’t AIDS. It’s malaria, a wily parasite that has plagued humankind and shaped our lopsided world for millennia.
"World Malaria Day" is April 25, and will undoubtedly be full of events and fundraisers drawing attention to the fight against malaria, and most importantly the need for people to step up and donate their dollars. Let’s remember, as we empty our wallets, the depths of our failures against this disease. We’ve known how to prevent and cure malaria for over a hundred years and yet-still, unforgivably-hundreds of millions are infected very year and scores perish. Worse, malaria infection leaves people much more vulnerable to other infections, including HIV. Why?
According to the editors of the esteemed journal Nature, part of the problem is that the public isn’t hearing the real story.
"The agencies involved in the malaria fight, including the WHO, have for too long been driven by advocacy," Nature complained in a February 28 editorial. The result: "good news spin" that prevents us from understanding the true complexities, challenges, and failures in the fight against this age-old pathogen. Minor, predictable gains are painted as major breakthroughs to maintain the donor support that our tepid fight against this neglected, forgotten disease requires. Meanwhile the microbe that causes malaria-the protozoan parasite Plasmodium, the malignant spawn of an ancient plant gone wrong-proceeds on its rounds, barely deterred. The fundraisers say all that is required is a $5 donation to buy a mosquito net for some vulnerable child. As if the failures to control this disease hinge upon some lack of charitability. If only it were so simple.
I’m standing on the Cameroonian shore of the Gulf of Guinea, a gray blob shimmering on the sea at the horizon. It’s Bioko Island, where Marathon Oil has built a giant natural gas installation, along with hundreds of neat ranch houses of the type that are commonly found in Texas. The ranch houses are supposed to be full of Texan oil workers and their families, but they are all empty. "Too much damn malaria," the late malariologist Andy Spielman, who consulted for Marathon, told me. Nobody wants to come and risk the bite of a local mosquito.
Malaria’s ability to stymie the most powerful companies on earth is testament to its longstanding capacity to transform the history of the landscapes in which it settles, from West Africa to London to Panama. The mosquito-borne disease is exquisitely sensitive to opportunities in newly disrupted ecologies, which is part of why it has proved such a powerful foe, for we alter our environment as surely as beavers build dams. From the streets of modern Panama City to the villas of ancient Rome, when malaria parasites are introduced into biologically altered landscape, they’ve exploited the opportunity, with far-reaching consequences.
The net effect of climate change on malaria is a matter of ongoing scientific controversy. What is clear is that our changing climate will exact its pounds of flesh, at least for some, in some places. It isn’t hard to see how. Take for instance the summer of 2005. The clouds never came to the Amazon River that year. The patch of warm ocean and rising air that unleashed Hurricane Katrina in the southeastern United States had the opposite effect across the Amazon river basin: instead of tempestuous rains, a lengthy drought. The long clear days of summer had a sudden effect on the river, whose serpentine gulleys carry a fifth of the planet’s fresh water. In September, the water level plummeted by nearly 2 feet every day. As the water level plunged, the fish started to smother. Soon, it was impossible to navigate a canoe down the muddy trickle. Thousands of boats were marooned on red, cracked earth. By December, the mighty Amazon had turned into a grassy swamp, and the Brazilian government was forced to airlift food, water, and medicines to over 800 towns and villages stranded along the former river’s banks.
Horacio Ramos had planned to drive his boat back 30 miles to his village, but the houseboat was stuck in the mucky riverbed. With all the local rivers dry, he said, "there’s no way back home."
While Ramos and scores of others idled hungrily, clinicians waited grimly for what appeared inevitable. Without the rains to flood them away, the eggs of millions of Anopheles mosquitoes would soon hatch. The flies would find the people weakened by hunger, lingering dazed around the still, dirty puddles left in the wake of their vanished river. And one day, a dormant malaria parasite-whether from Cameroon, India, or a few miles upstream-would awaken, and sense its opportunity.
Multiply this picture times one hundred, and you can begin to see the new malaria landscape emerging.
Malaria is largely a forgotten disease in the most powerful countries of the West. Political will to challenge malaria waxes and wanes within the limits of the political and business ambitions of Western leaders. It is ironic, in a way, since malaria flourished as lushly in these regions as it does today in sub-Saharan Africa. Malaria once spread across the United States, from Massachusetts to Florida to Iowa and California.
But in the world’s economic centers, malaria receded before anyone really understood much about it, with the result that we’ve been able to indulge our most cherished vanities about why. In the United States, the peculiar history of malaria’s recession (our wanton destruction of mosquito-breeding wetlands had much to do with it) gave rise to the unspoken notion that malaria is mainly a business problem; in Britain, to the idea that malaria is mostly the inevitable result of poverty. In other words, anything but the peculiar ecological and demographic disease that it is.
And so with the most accessible natural resources of the West largely in decline, from minerals to timber, Western companies now exploit the more distant, difficult resources of the tropics. But far from alleviating malaria, the new "economic development in agriculture and mining" was fingered by the WHO in the early 1990s as culprits in the spread of malaria, especially in their leading frontiers, where war and lawlessness reign. The highways built through the Brazilian Amazon brought settlers, workers, and new development projects to the region, for example, but the jungle’s mosquitoes feasted upon the non-immune newcomers regardless, transmitting residual parasites darting in their guts. Human flesh was too conveniently available, laid out in crude houses perched along the region’s newly felled rivers and lakes.
In the late 1990s, more than 120,000 fell prey to falciparum malaria in Peru, compared to under 150 cases a year earlier in the decade. The fast-falling rainforest, far from depriving the local malarial mosquito Anopheles darlingii of the shady, fast-flowing streams they liked to breed in, had proved fruitful for the flies, which settled thickly in the disturbed lands around new man-made fish farms and ponds.
With political commitment limited and scientific consensus scarce, only a magic-bullet technology-something awe-inspiring, super-potent and fast-unites the scientific and political community to turn against malaria, en masse. DDT, promoted by chemical warriors and pro-business American public health leaders after World War II, was just the thing.
Africa was purposely excluded from the 1950s "global" malaria eradication campaign which sent DDT sprayers fanning across the globe. When DDT-resistant mosquitoes started to fly, the campaign refocused on another chemical onslaught: the antimalarial drug chloroquine, which was in some places added to the table salt. When chloroquine-resistant parasites started to spread, political commitment to the program dissipated.
It took just three decades for drug-resistant malaria to sweep across the globe, carried by mosquitoes coolly impervious to the most deadly insecticides known to man. By the late 1990s, deadlier, faster, and harder-to-contain resistant malaria was annexing whole new swaths of the planet, from the war zones of Afghanistan and the highlands of Kenya to the banks of the Panama Canal and the alleys of Mumbai. The death toll, compared to 1961, quadrupled.
The parasite continually invades its former stomping grounds, in the 1,200 malarial travelers, refugees, soldiers, and miners that toss and turn on American hospital and clinic beds every year. Little besides sheer metal mesh prevent the parasites from re-entering the hungry Anopheles mosquitoes outside, re-igniting an epidemic. Anopheles flit in every state of the U.S. union, save for Hawaii, and the swarms double in size for every half-degree uptick in the global temperature.
The sun streams into the squat, whitewashed Red Cross malaria clinic, the cerulean sea lapping the shore visible from its open-air windows. Fishermen are untangling their netting on the beach. Inside, there are 2 small rooms, with 2 small cots, and a dozen silent workers wearing bright white smocks to tend to the hundreds of villagers who patronize this humble facility.
This clinic is in the right place, a small village outside Douala, Cameroon, where nearly every inhabitant is infected with malaria parasites. With the right drugs, given at the right time, they could render malaria absolutely toothless. For almost as long as we’ve had malaria, we’ve known about potent compounds that vanquish the parasite. Many come from plants, the weedy type that can grown almost anywhere.
But the steel medicine cabinet, when I peek into it, is bare. I count maybe a dozen small vials. I’ve got more drugs in my bedside table at home.
The one drug that effectively treats multi-drug resistant malaria is based on an ancient Chinese medicine called artemisinin, an extract from the sweet wormwood tree. But political disinterest and profit-driven drug companies have already compromised its effectiveness.
It is essential that the drug is taken in combination with other drugs, so that the parasite is not able to evolve resistance to this one last cure. Throughout the 1980s and 1990s, drug companies did just that, selling stand-alone artemisinin drugs throughout Africa and Asia. By 1994, Chinese scientists, who had formulated a combination artemisinin drug, sold the rights to drug giant Novartis. But Novartis didn’t launch the combination drug until 1999, and when they did, they priced it at $44 per course.
When the WHO declared that the Novartis drug should be the first-line drug against malaria, in 2001, Novartis dropped the price to $2/course, but that was still 10 to 20 times more expensive than the older-but useless-malaria drugs like chloroquine. And Western aid organizations refused to foot the bill. According to USAID’s Dennis Carrol, despite the WHO’s recommendation, Coartem was "not ready for prime time." In a 2003 malaria epidemic in Ethiopia, UNICEF expressly refused to pay for and distribute artemisinin combination drugs. There wasn’t enough supply on hand, they said, and the new drug therapy would cause confusion.
African and malaria aid physicians were appalled. "I couldn’t believe my ears," said Ghanian epidemiologist Fred Binka. Donors’ reluctance was "frankly, very difficult to understand," said MSF’s Bernard Pecoul. But without USAID or other funders’ support, there was no way developing countries’ health ministries could weather a 10-fold increase in malaria drug prices.
In the financial and regulatory vacuum, the underground market in stand-alone artemisinin drugs continued to thrive. By 2004, the parasite had been widely exposed to stand-alone artemisinin, and had started to evolve resistance. Artemisinin combination drugs might still work on these parasites, but probably not for long, commentators in the Lancet noted. For the first time ever, the WHO publicly criticized the drug companies that sold stand-alone artemisinin drugs, demanding that the industry immediately stop marketing the drugs.
"It will be at least 10 years before a drug that good is discovered," bemoaned the WHO’s Arata Kochi, referring to artemisinin. "Basically we’re dead."
New resolve to tackle malaria emerged in the late 1990s and early 2000s, in the wake of intensifying business interest in the natural resources of Africa. Led by business leaders such as ExxonMobil and Bill Gates, malaria’s new challengers brazenly call for a fight to the finish. Working toward anything less than complete eradication of malaria from the face of the earth, Bill Gates said in October 2007, would be to admit defeat.
And yet, controlling environmental disruptions that aggravate malaria, building better housing that separates human from mosquito, and public-health-oriented drug development and distribution remain, effectively, off the table. Gates and Exxon et al want more money for high-tech vaccine research, and to distribute mosquito nets doused with insecticides. It is something, but it cannot be called enough.
Fighting malaria with chemicals alone is a battle we can’t realistically hope to win. Until we come up with a better way, malaria remains as it always has been, our cross and consort.
Sonia Shah is the author of The Body Hunters: Testing New Drugs on the World’s Poorest Patients (2006) and creator of a new website devoted to independent commentary on malaria, ResurgentMalaria.com. Her book on the history and politics of malaria is forthcoming from Farrar, Straus & Giroux in 2009.