Over 65 million men served in the First World War between 1914 and 1919. Roughly 10 million were killed and another 25 million wounded.* An estimated 1.5 million soldiers contracted a mosquito-borne disease, including my teenage malaria-gifted great-grandfather William Winegard. Unlike 95,000 others, he survived, thankfully. Given the sheer number of men who fought and died, these statistics are paltry. Mosquito-borne disease accounted for less than 1% of all war-related deaths—a far cry from her inventory of the past. Given her quarantined isolation in no-man’s-land, the lonely mosquito did not alter the outcome of this global Great War for Civilization. The conflict was decided beyond her scouring reach by a war of attrition waged in the stagnant trenches on the Western Front, zigzagging like an angry scar for 450 miles from the Swiss Alps to the Belgian coast on the North Sea and, to a far lesser extent, on the Eastern Front prior to the 1917 Russian Revolution and the ensuing civil war.
In the immediate fraudulent peace of the post-Versailles era, however, disease was far more lethal than it had been during the war itself. Abetted by cramped and squalid trench conditions and repatriation centers harboring soldiers returning to all four corners of the globe, the roving 1918–1919 influenza epidemic infected over 500 million people, killing upwards of 75 to 100 million worldwide, five times more than the world war that helped it go viral.* Influenza was not the only disease spread by homeward-bound veterans, although it has overshadowed all others in our collective memory. Australia, Britain, Canada, China, France, Germany, Italy, Russia, and the United States, among numerous other nations, all witnessed spikes of malaria. During the interwar years, the mosquito made up for lost time, unleashing a deluge of disease. Despite our realization that the mosquito caused malaria, yellow fever, filariasis, and dengue, it still proved difficult to stunt her dealings in death, even in affluent Western nations.
The average global malarial infection rate during the decade of the 1920s, for example, was calculated to be an astonishing 800 million per year, producing an annual death rate of 3.5 to 4 million. In the United States, 1.2 million Americans contracted malaria during the 1920s, slackening to 600,000, including 50,000 deaths, the following decade. Dengue was also roaring across the American South, infecting 600,000 Texans in 1922, including 30,000 in Galveston alone. A casual observer imparted the wisdom that attempting to whitewash mosquito-borne disease was as pointless as “a one-armed man [trying to] empty the Great Lakes with a spoon.” During the 1930s, mosquito-borne disease was costing the United States an annual average of $500 million, up from $100 million at the turn of the century. When the Yangtze River in China flooded in 1932, malaria infections in affected areas reached 60%, causing a body count of over 300,000. Over the next five years, malaria ravaged an estimated 40 to 50 million Chinese. The newly minted Soviet Union, forged by revolution and civil war, was swallowed by mosquitoes.
The 1917 Bolshevik Revolution knocked Russia out of the war and eroded the Eastern Front. The ensuing Russian Civil War devastated populations, landscapes, and health services across the former czarist Romanov Empire. A tragic Malthusian ecological disaster of flooding, famine, and pestilence quickly followed, killing as many as 12 million Russians before the conclusion of the Civil War in 1923. Although the triumphant Red Army of Lenin, Trotsky, and Stalin provided the sweeping introduction of the Soviet Union and communism as a rival political, military, and economic global menace to Western democracies, this historic event was also accompanied by a tidal wave of disease and deprivation.
While Lenin was ruthlessly consolidating his power, vivax and falciparum malaria latched on to both the Great Famine and a catastrophic eruption of typhus and then thundered across the entire Soviet Union as far north as the glacial port of Archangel, situated roughly 125 miles below the Arctic Circle on a latitudinal line with Fairbanks, Alaska. This 1922–1923 Arctic epidemic reveals that with the perfect storm of temperature, trade, civil strife, suitable mosquitoes, and a vectoring warm-blooded human population, the scourge of malaria has no boundaries or territorial parameters. It is estimated that this peculiar and bewildering flurry of polar malaria infected 30,000 people, killing 9,000. According to historian James Webb, “in 1922 to 1923, the greatest European malaria epidemic of modern times struck.” In the hardest-hit areas of the Volga River basin, southern Russia, the Stans, and the Caucasus, regional infection rates climbed between 50% and 100%. In 1923 alone, there were an estimated 18 million cases of malaria across the Soviet Union, with 600,000 deaths. The corresponding flea-borne typhus epidemic peaked between 1920 and 1922, blighting 30 million and killing 3 million Russians before tapering off in 1923, the same year the cyanide-based pesticide Zyklon B was developed in Germany.* Malaria spiked again across the Soviet Union in 1934 with a caseload of almost 10 million. Given this distressing uptick in mosquito-borne disease during the interwar years, probing medical research and mosquito eradication programs gained momentum. While the meat-grinding conflict of the Great War and its violent aftershocks groaned and staggered to a halt, our battle in the trenches against our mosquito nemesis continued.
“Destroy Mosquito Larvae”: The statement in the bottom left of this 1942 Soviet mosquito eradication poster references the war on mosquitoes and swamps. The Soviet Union/Russia had a long history with malaria. During the worst recorded European outbreak in 1922–23 following the Russian Revolution and the ensuing Civil War, malaria struck as far north as the Arctic port of Archangel. In 1923 alone, there were an estimated 18 million cases of malaria, including 600,000 deaths in the Soviet Union. (U.S. National Library of Medicine)
Within this ongoing scientific struggle against both mosquito-borne disease and mosquitoes themselves, an altogether strange breakthrough occurred in 1917. While researching treatments for neurosyphilis, Austrian psychiatrist Dr. Julius Wagner-Jauregg came up with the half-baked idea of injecting his patients with a nonlethal, but still debilitating, strain of malaria to cure their late-stage insanity-delivering syphilis. It worked. Malarial fevers reaching 107 degrees Fahrenheit (42 Centigrade) charbroiled the heat-sensitive bacteria. Patients traded surefire, agonizing syphilitic death for saddling malaria, which I suppose is the lesser of two evils. The mosquito was now both a killer and a savior, although Jauregg counseled that “malaria therapy was still malaria.” His treatment gained prominence and by 1922, malaria therapy was being prescribed to syphilitic patients in numerous countries, including the United States. By 1927, the year Jauregg won the Nobel Prize for his insane yet innovative remedy, American clinics had wait lists to “take” malaria like some kind of quick-fix pill. Thankfully, with the discovery of the world-altering antibiotic penicillin by Alexander Fleming a year later, the demand for Jauregg’s malarial antidote fizzled out. Patients could now be cured of syphilis (and other bacterial infections) without being stung with malaria. Global mass production of penicillin began in 1940.
Generally, however, less invasive advances were unearthed during the interwar years to combat our most lethal enemy. Cinchona plantations expanded from South America, Mexico, and Dutch Indonesia to other parts of the world. Small and scattered coppices and thickets of cinchona trees eventually took root in British India and Sri Lanka and in the US territories of the Philippines, Puerto Rico, the Virgin Islands, and Hawaii. Mosquito control boards were established across the United States and other mosquito-infested countries and colonies. In 1924, the League of Nations, a feeble precursor to the United Nations, established its Malaria Commission under the canopy of its larger international health organization. The Rockefeller Foundation, conceived in 1913 by American Standard Oil tycoon John D. Rockefeller, was a revolutionary model of philanthropy replicated by many future charitable organizations, including the exemplary Gates Foundation. By 1950, under the motto of “promoting the well-being of humanity throughout the world,” the Rockefeller Foundation had allocated $100 million to mosquito control and malaria and yellow fever research, among a host of other health-related endeavors.
The most audacious and successful interwar mosquito eradication program, however, was carried out on the distinguished Pontine Marshes by Benito Mussolini. The Italian dictator made the eradication of malaria via the draining of the Pontine Marshes one of his top priorities. For his National Fascist Party, it was a means of winning hearts and minds, expanding agricultural development in the uninhabited area, breeding “great rural warriors,” and illuminating Mussolini’s “second Italian Renaissance” for the world. His integral reclamation program began in earnest in 1929, when the life expectancy of a farmer in Italy’s malarial regions was a dismal 22.5 years. A preliminary census of the Pontine Marshes found no permanent settlements and only 1,637 “web-toed, fever-ridden corkcutters” occupying dilapidated thatched huts. The report also warned that 80% of people who spent one day in the marshes could expect to contract malaria.
In the first of three stages, the swamps and tidal waters were drained or dammed. The “battle of the swamps,” as the Fascist Party styled it, required an involuntary labor force, which peaked in 1933 at 125,000 men, most of whom were dubbed “racially inferior” Italians. Over 2,000 were also subjected to malaria medical experiments. In the second stage, stone-house homesteads and public utilities were constructed and the land was parceled out among forcefully relocated settlers. The third stage took measures against mosquitoes, such as window screens, sanitary improvements, and health services, and against malaria, by distributing quinine from well-stocked strategically placed depots.
Beginning in 1930, malaria-ridden workers cleared targeted undergrowth, planted over a million pine trees, and assembled hydraulic pumping stations along an astounding 10,300-mile-long checkerboard of newly constructed canals and dikes, including the Mussolini Canal, which empties harmlessly into the Tyrrhenian Sea near Anzio. Mussolini used the decade-long operation as a propaganda crusade, often posing shirtless with a shovel or wheat thresher in hand or atop his red motorcycle for photographs or newsreels among the sickly (but smiling) workers or picnicking lovers. Five architecturally distinct model towns were built between 1932 and 1939, including Latina, Aprilia, and Pomezia, along with eighteen rural satellite villages. Mussolini’s advertising aside, his reclamation and eradication program, one of the first of its kind, was a resounding success. Malaria rates in the former marshes, and throughout Italy, plummeted by 99.8% from 1932 to 1939. During a few weeks in 1944, however, in a brazen act of biological warfare, the Nazis systematically reversed years of antimalarial gains.
Although mosquito research hit fever pitch during the interwar years, it would take a covert American Second World War program akin to the nuclear Manhattan Project to finally bite back at the mosquito, using newfangled synthetic antimalarial drugs and the mosquito-slaying services of DDT. Although DDT was first synthesized in 1874 by German and Austrian chemists, it was not until 1939 that German Swiss scientist Paul Hermann Müller recognized its insecticidal properties, earning him the 1948 Nobel Prize “for his discovery of the high efficiency of DDT as a contact poison against several arthropods.”
Müller originally worked on organic plant-derived dyes and tanning agents, but his love of the outdoors and the flora and fauna of the natural world (and eating fruit) led him to experiment with plant-protection chemicals, including disinfectants. By observing and studying insects, Müller realized that these creatures absorbed chemicals differently from humans and other animals. He was also stirred to action in 1935 by a dire food shortage in Switzerland caused by insect crop infestation and by the lethal epidemic of typhus in Russia, mentioned earlier, and its extensive diffusion across eastern Europe. Determined to save lives, safeguard farms, and preserve his cherished fruit trees, Müller set out on his mission to “synthesize the ideal contact insecticide—one which would have a quick and powerful toxic effect upon the largest possible number of insect species while causing little or no harm to plants and warm-blooded animals.” After four years of fruitless laboratory experiments on 349 unserviceable chemicals, number 350—DDT—was the magic bullet.
Following successful trials on the common housefly and the ruinous Colorado potato beetle, a series of rapid-fire tests on other pests revealed that DDT killed fleas, lice, ticks, sandflies, mosquitoes, and a swarm of other insects with astonishing effectiveness and efficiency—dispatching typhus, trypanosomiasis, plague, leishmaniasis, malaria, yellow fever, and a host of other vector-borne diseases in the process. The insecticidal mechanisms of DDT operate by quickly scrambling the proteins and plasma of sodium ion channels and neurotransmitters, disrupting the nervous system of its target, which leads to spasms, seizures, and death. In September 1939, as the Nazis and Soviets were carving up Poland under the Molotov-Ribbentrop Pact and triggering the Second World War, Paul Müller was in the Geigy AG (now the pharmaceutical giant Novartis) laboratory in Basel, Switzerland, activating the chemical age of DDT.
Despite DDT’s German derivation, Hitler, on the advice of his personal physician, who considered DDT useless and dangerous to the health of the Reich, prevented its use by German forces, until it was employed judiciously in 1944. In contrast, by 1942, the United States had already begun mass production for the war effort, in conjunction with a colossal Malaria Project that was afforded the same levels of secrecy, security, and scope as the nuclear Manhattan Project. Both atomic weapons and DDT canisters were added to the Allied arsenal.
The US War Department created the Army School of Malariology in May 1942, and trained specialized cadres dubbed “Mosquito Brigades” or “Dipstick Soldiers,” officially known as Malaria Survey Units, within the new military Division of Tropical Medicine. Wielding their DDT-spraying magic wands, these unconventional pioneering mosquito soldiers entered the war in Allied areas of operation in early 1943, hoping to make the mosquito dissolve and vanish. While DDT targeted the mosquito directly, it did not attack the disease of malaria itself. At the onset of war, this honor was reserved exclusively for quinine. An additional catalyst for the creation of the Malaria Project was the Japanese stranglehold on global cinchona plantations and quinine supplies.
The rapid Japanese expansion across the Pacific in early 1942 included the Dutch East Indies and its 90% global share of cinchona production. The capture of this quinine, along with petroleum, rubber, and tin, was key to Japanese military planning, with Germany also benefiting from large shipments. For the Allies, the lack of quinine posed a significant problem and a serious military setback. With limited and inadequate amounts of cinchona trickling in from India, South America, and overseas US territories, artificial alternatives were paramount to the prosecution of the war. Working under the umbrella and patronage of the Malaria Project, American chemists scrambled to action and the hunt for a synthetic cinchona-quinine substitute began in earnest.
Over 14,000 compounds were tested, including derivatives of mefloquine and malarone, which would be shelved until chloroquine resistance first appeared in 1957. Leo Slater explains in War and Disease, his study of the biomedical research on malaria, “In 1942 and 1943, the antimalarial program would find itself with three main scientific (and clinical) priorities: Synthesizing new compounds, understanding atabrine, and developing chloroquine. . . . On the heels of atabrine’s development as the drug of choice, superseding quinine, would come chloroquine, a drug with newfound promise . . . but it would not emerge from clinical testing until after the end of hostilities.” In 1943, atabrine production reached 1.8 billion tablet doses and increased to 2.5 billion in 1944.* While all Allied servicemen received their yellow fever vaccine injection, field commanders could not guarantee that they ingested their partially effective atabrine pills.
Given the side effects both real and rumored, many didn’t. It left a bitter taste, caused yellowing of the skin and eyes and off-color urine, and triggered head and muscle aches. In rare cases it led to vomiting, diarrhea, and psychosis.* Atabrine did not, however, cause impotence and sterility, a GI gossip item that was quickly exploited by German and Jap
anese propaganda to diminish Allied morale, fighting strength, and manpower. By snubbing their atabrine, the enemy hoped, Allied soldiers would swap malaria as casually as they traded and bartered cigarettes, chewing gum, Hershey “D Ration” bars, and the pinup bombshells Rita Hayworth, Betty Grable, and Jane Russell.*
“These Men Didn’t Take Their Atabrine”: A sign posted outside the 363rd US Station Hospital in Port Moresby, Papua New Guinea, during the Second World War, warning Allied troops to take the antimalarial drug atabrine. Many soldiers did not take their daily dose as it caused yellowing of the skin, eyes, and off-colored urine, and triggered headaches, muscle pain, vomiting, and diarrhea. In rare cases it led to temporary or permanent psychosis, similar to modern-day mefloquine. (National Museum of Health and Medicine)
While mosquito nets were also a mandatory piece of kit, one soldier summed up their actual value. The troops, he remembered, “had neither the time nor the strength to bother about mosquito bars and head nets and gloves.” Some soldiers purposefully renounced all malarial precautions in order to be taken out of the line, something commanders referred to as “malarial desertion,” extremely difficult to prove and prosecute as a military offense. Prudent, switched-on officers went so far as to dole out atabrine tablets during roll call and have troops urinate on sight to produce visual evidence that they were compliant with orders. Generally, however, for combatants of all nationalities in the Pacific theater, malaria was, as one soldier put it, “inevitable and just a part of doing business as usual.” Even with DDT and atabrine, the statistics for mosquito-borne disease were shockingly high. We can only guess at what malaria rates would have looked like without these two lifesaving scientific breakthroughs.
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