A very different outcome awaited those who fought to eradicate malaria worldwide. Between 1958 and 1963 alone, $430 million was spent on a series of failed attempts to eliminate malaria. In 1991 dollars that constituted an expenditure of over $1.914 billion.31 Between 1964 and 1981, the United States spent an additional $793 million. 32
When the international effort began, there were millions of cases of malaria every year, largely concentrated in Southeast Asia and Africa. Though reliable numbers were not available for most parts of the world, it was estimated that, for example, about 1 million people had malaria that year in Sri Lanka, some 100 million in India, and untold numbers, roughly estimated in the “hundreds of millions,†in Africa.33
On the other hand, humanity possessed powerful weapons. Chloroquine and quinine were effective treatments that, when properly and speedily used, stopped most cases of the disease in a matter of days. And chlorinated hydrocarbon insecticides—notably DDT34—could kill not only adult mosquitoes that carried malarial parasites but their progeny as well, because the chemicals were virtually nonbiodegradable and their insect toxicity could be expected to eliminate pests that landed on sprayed surfaces for months, even years, after chemical treatment.
Even without such chemical weapons, some countries had dramatically reduced their malaria problem; chief among them was the United States. There was disagreement in research circles about the origins of malaria in the Americas,35 but whatever the case, by the eighteenth century malaria was a serious endemic disease from Montreal to southern Chile.
For the U.S. military, malaria was an enormous problem—in some theaters of combat, its chief hardship—since the creation of George Washington’s Continental Army in 1776. At least a million soldiers suffered malaria during the Civil War, and the disease was a major killer in America’s southern states well into the 1930s. U.S. troops also suffered serious malaria problems overseas; 19,000 doughboys contracted the disease during World War I, and over 500,000 GIs had malaria during World War 11.36
But during the construction of the Panama Canal (1904–14), General William C. Gorgas directed the U.S. Army Medical Corps on a successful campaign to drain swamps, treat local people with quinine, and kill mosquito larvae floating atop pools of water. He did not have DDT at his disposal in those early years, yet the result was virtual eradication of Panamanian malaria. Similar drainage efforts throughout the U.S. sunbelt were already bringing malaria down to negligible levels by 1947.37
Then Egypt embarked on the first successful campaign using DDT to eliminate the Anopheles gambiae mosquito. Its initial results were so dramatic that the U.S. Congress allocated $7 million in 1947 for a DDT-based program to eradicate malaria within the forty-eight states. Five years later, the program was abandoned when not one case of malaria could be found within the U.S. borders.
Similar successes were reported across the European continent, though malaria stubbornly hung on in parts of Italy, Spain, and Greece well into the 1950s. Buoyed by Brazil’s success a decade earlier controlling the A. gambiae38 mosquito population, the 1954 Pan American Sanitary Conference held in Santiago, Chile, resolved to eradicate malaria-carrying mosquitoes from all countries in the Americas, from the Arctic to Antarctica.
In 1956, malariologist Paul Russell, then at Harvard University’s School of Public Health, authored a report for the International Development Advisory Board (IDAB)39 recommending immediate global eradication of malaria. In the report Russell reflected mainstream scientific views of the day when he argued that DDT was such a powerful tool that a multimillion-dollar worldwide campaign could eliminate all malaria-carrying mosquitoes on the planet within less than a decade.
Generally, it takes four years of spraying and four years of surveillance to make sure of three consecutive years of no mosquito transmission in an area. After that, normal health department activities can be depended upon to deal with occasional introduced cases … . Eradication can be pushed through in a community in a period of eight to ten years, with not more than four to six years of actual spraying, without much danger of resistance. But if countries, due to lack of funds, have to proceed slowly, resistance is almost certain to appear and eradication will become economically impossible. Time is of the essence [his emphasis] because DDT resistance has appeared in six or seven years.40
Lest anyone in Congress miss the IDAB report’s point, Russell added the following strong words:
This is a completely unique moment in the history of man’s attack on one of his oldest and most powerful disease enemies. Failure to proceed energetically might postpone malaria eradication indefinitely.
Russell’s plan caught the imagination of several key figures in the American political arena of the late 1950s: Secretary of State George Marshall, Senators John F. Kennedy and Hubert H. Humphrey, and President Dwight D. Eisenhower. Though malaria no longer existed in the United States, America was, in 1957, the center of virtually all cash reserves on earth. Europe, Japan, and the U.S.S.R. were still smarting from World War II devastation, and what is now called the developing world was largely in the yoke of colonialism or severe underdevelopment. Having won World War II, Americans were of a mind to “fix things upâ€: it just seemed fitting and proper in those days that Americans should use their seemingly unique skills and common sense to mend all the ailments of the planet.
Thus, in 1958 Russell’s battle for malaria eradication began, backed directly by $23.3 million a year from Congress.41 Because Russell had been so adamant about the time frame, Congress stipulated that the funds would stop flowing in 1963. In addition to the $23.3 million to be spent annually by IDAB, Congress shelled out funds generously between 1958 and 1963 for WHO (contributing 31 percent of its overall budget and more than 95 percent of its malaria budget), the Pan American Health Organization (PAHO, which got 66 percent of its funds directly from the U.S. Congress), and UNICEF (underwriting 40 percent of the UN Children’s Fund budget).42 It was a staggering economic commitment, the equivalent of billions of dollars in 1990. Remarkably, American politicians didn’t complain about spending so much money to control diseases few U.S. citizens ever contracted, and the effort enjoyed bipartisan support. President Eisenhower called for the “unconditional surrender†of the microbes, George Marshall foresaw the “imminent conquest of disease,†and Senator Kennedy predicted that children born in the next decade would no longer face the ancient scourges of pestilence.
The stage was set. The scientists had everything going for them: political support, money, DDT, and chloroquine. So certain were they of victory that malaria research came to a virtual halt. Why research something that will no longer exist?
Yet when Andy Spielman had started graduate school just five years earlier at Johns Hopkins School of Medicine, the budding young Colorado scientist was convinced he would have a lifetime’s worth of parasite research puzzles to solve. Socially awkward because of a stuttering speech impediment, Spielman delighted in the introspective world of science. Baltimore colleagues quickly admired his wit, warmth, and ready intelligence. Spielman anticipated decades of studying insects and the parasites they carried.
He had, however, been in Baltimore less than two months when his mentor, Lloyd Rozeboom, grabbed Spielman by the collar and said, “Let’s get a beer.â€
The downcast Rozeboom bought Spielman a pint and after a few quaffs said, “Look, I’ve got to get this off my chest. I’m conscience-stricken.â€
“What’s the problem?†Spielman asked.
“I should never have accepted you into graduate school. I should never have encouraged you to pursue medical entomology. It’s a dead field. DDT is killing it,†Rozeboom said.
Spielman argued it was too early in the game to call the score. But Rozeboom was adamant.
“It’s all over. There will be no career for you. By the time you
’ve finished your thesis all the insect-borne disease problems will be solved,†Rozeboom insisted.
Undaunted, Spielman pursued his Ph. D. despite Rozeboom’s warning. He was a firm believer in evolution—he had practically memorized his favorite text on the subject—and he told Rozeboom that “DDT isn’t the final answer.â€
While Congress reviewed Russell’s IDAB proposal, Spielman took some courses at the Woods Hole Oceanographic Institute in Massachusetts. There he met a middle-aged marine biologist who was quietly rethinking the whole DDT question. She told Spielman that evolution would come between DDT and the dream of malaria eradication. DDT-resistant strains of Anopheles mosquitoes were turning up all over the world, she said.
Her name was Rachel Carson, and the same year the United States and WHO embarked on their ambitious campaign to eliminate malarial mosquitoes, Carson started writing Silent Spring.43 Carson never completely opposed pesticide use; rather, she favored their rational and limited application. Prophetically, she worried that widespread agricultural use of insecticides would endanger efforts to control malaria, typhus, African sleeping sickness, yellow fever, and encephalitis. She wrote:
No responsible person contends that insect-borne disease should be ignored. The question that has now urgently presented itself is whether it is either wise or responsible to attack the problem by methods that are rapidly making it worse. The world has heard much of the triumphant war against disease through the control of insect vectors of infection, but it has heard little of the other side of the story—the defeats, the short-lived triumphs that now strongly support the alarming view that the insect enemy has been made stronger by our efforts. Even worse, we may have destroyed our very means of fighting.44
She noted that the first public health use of DDT occurred in 1943. Allied troops sprayed the chemical liberally to eliminate typhus-carrying lice in Italy. The lice were, in fact, killed, and typhus halted, but a year later DDT-resistant Culex mosquitoes and houseflies stepped into the vacuum. By 1951, mosquitoes and flies in the region were resistant to DDT, methoxychlor, chlordane, heptachlor, and benzene hexachloride, and Italians had returned to time-honored tactics for insect control: screened windows, flypaper, and flyswatters.
In 1959 Spielman joined the faculty of the Harvard School of Public Health and discovered that no courses on malaria or Anopheles mosquitoes were on the curriculum. With the leader of the world’s malaria eradication campaign on the faculty, it was considered distasteful to offer such courses. Training young scientists in techniques of mosquito control implied that Paul Russell’s efforts would fail and such knowledge would actually be necessary for future practitioners of public health.
Russell, an ex-missionary, was a kindly, elderly gentleman, and although Spielman had never believed the campaign would succeed, it broke his heart to see the dejection Russell felt when 1963 arrived.
Malaria had, indeed, reached its nadir. But it had not been eliminated. In some countries success was so close that people were already celebrating. Sri Lanka, for example, had 1 million malaria cases in 1955; just eighteen in 1963.
But a deal’s a deal. Russell promised success by 1963, and Congress was in no mood to entertain extending funds for another year, or two. As far as Congress was concerned, failure to reach eradication by 1963 simply meant it couldn’t be done, in any time frame. And at the time virtually all the spare cash was American; without steady infusions of U. S. dollars, the effort died abruptly.
In 1963 Harvard put malaria control back on its curriculum.
Spielman shook his head and wondered out loud, “How can they just abandon all these people?†He knew that, thanks to the near-eradication effort, hundreds of millions of people now lacked immunity to the disease, but lived in areas where the Anopheles would undoubtedly return. Pulling the plug abruptly on their control programs virtually guaranteed future surges in malaria deaths, particularly in poor countries lacking their own disease control infrastructures. As malaria relentlessly increased again after 1963, developing countries were forced to commit ever-larger amounts of scarce public health dollars to the problem. India, for example, dedicated over a third of its entire health budget in 1965 to malaria control.45
Everything started to unravel. The Green Revolution—a World Bankbacked scheme to improve Third World economies through large-scale cash crop production—got underway. Turning thousands of acres of formerly diversely planted and fallow land into monocultured farms for export production of coffee, rice, sorghum, wheat, pineapples, or other cash crops necessitated ever-increasing pesticide use. When an area had very diverse plant life, its insect population was also diverse and no single pest species generally had an opportunity to so dominate that it could destroy a crop. As plant diversity decreased, however, competition and predation among insects also declined. As a result, croplands could be overwhelmed rapidly by destructive insects. Farmers responded during the 1960s with heavy pesticide use, which often worked in the short term. But in the long run pesticides usually killed off beneficial insects, while the crop-attacking pests became resistant to chemicals. A vicious cycle set in, forcing use of a wider assortment of insecticides to protect crops.
At the very time malaria control efforts were splintering or collapsing, the agricultural use of DDT and its sister compounds was soaring. Almost overnight46 resistant mosquito populations appeared all over the world.
As Russell kept a worried eye on the pesticide resistance problem, a new crisis appeared: two people who were taking chloroquine developed malaria in South America.47 Almost simultaneously, chloroquine-resistant malaria turned up in Colombia,48 Thailand,49 Venezuela,50 and Brazil.51 The drug had been in use for only fifteen years; widespread use spanned less than a decade’s time.52 By 1950 a second drug, primaquine, was available, and many countries returned to the use of the ancient antimalarial, quinine. But resistance soon developed to those and other drugs introduced in the 1960s.53 By 1963 U.S. forces fighting in Vietnam encountered chloroquine-resistant malaria, and the Army began a major effort to research and develop new antimalarial drugs.54
The drug-resistance problem could only have been aggravated by government decisions in some countries—notably New Guinea—to add chloroquine to all table salt.55
By the time the smallpox campaign was approaching victory in 1975, parasite resistance to chloroquine and mosquito resistance to DDT and other pesticides were both so widespread that nobody spoke of eliminating malaria. Increasingly, experts saw the grand smallpox success as an aberration, rather than a goal that could easily be replicated with other diseases.56
In 1975 the worldwide incidence of malaria was about 2.5 times what it had been in 1961, midway through Paul Russell’s campaign. In some countries the disease was claiming horrendous numbers of people. China, for example, had an estimated 9 million cases in 1975, compared to about 1 million in 1961. India jumped in that time period from 1 million to over 6 million cases.57
A new global iatrogenic form of malaria was emerging—“iatrogenic†meaning created as a result of medical treatment. In its well-meaning zeal to treat the world’s malaria scourge, humanity had created a new epidemic.
3
Monkey Kidneys and the Ebbing Tides
MARBURG VIRUS, YELLOW FEVER, AND THE BRAZILIAN MENINGITIS EPIDEMIC
When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.
—René Dubos
The failures of malaria eradication were overshadowed by the tremendous triumphs of polio control and the campaign for the elimination of smallpox. Western scientists in the late 1960s saw the history of disease as an arrow shooting straight toward a Homo sapiens victory over the microbes. Machupo was considered a distant anomaly, news of which hadn’t reached most Western physicians or scientists. And more than another decade would pass before th
e global public health community would stop using the term “eradication†when referring to malaria.
But other “anomalies†soon followed.
I
In August 1967 three factory workers in Marburg, Germany, reported in sick, suffering from muscle aches and mild fevers. The three men were employed at Behringwerke AG, the vaccine-producing subsidiary of pharmaceutical giant Hoechst AG, and though their ailments looked like nothing more than the flu, it was quite unusual for influenza to appear during Germany’s hot summer months. The men were referred to the Marburg University Hospital.
The following day the three became nauseated, their spleens enlarged and were tender to the touch, and their eyes became increasingly bloodshot. The attending physicians noted that “the patients had a sullen, slightly aggressive or negativistic behavior.â€1
Day by day more workers from the pharmaceutical plant fell ill, as did a doctor and a nurse who tended the patients. By September, twenty-three patients lay in agony in the Marburg University Hospital wards. Some fifty miles away in Frankfurt, six more individuals contracted the same mysterious disease at the German government’s Paul Ehrlich Institute. Four were also workers employed in pharmaceutical research, one was their treating physician, and the sixth was a pathologist who performed laboratory analysis of the cases.
At the same time a third outbreak occurred in Belgrade, Yugoslavia, involving a veterinarian and his wife.
The thirty-one cases struck terror in European research circles because of the ferocity of the disease and its spread from patients to their health care providers. Nobody knew what caused the ailment, how it was spread, what treatments might be effective, and/or how many more people might eventually be stricken.
The Coming Plague Page 8