The Fever
Page 13
And so, between 1999 and 2004, 95 percent of children with malaria in Africa got treated with the old standby chloroquine. At least half the time, the drug failed to work. Some patients improved slightly, and perhaps felt a bit better, thanks to the drug’s fever-reducing effects,176 but they remained infectious, and were likely to relapse. Others simply failed to recover at all.177
This situation, after the world’s leading health authorities had clearly sanctioned better drugs, led to a huge and caustic outcry among African and malaria aid physicians. Donors’ reluctance was “frankly, very difficult to understand,” said Médecins Sans Frontières’ Bernard Pécoul.178 “I couldn’t believe my ears,” said Binka. “If a physician went to Burma and prescribed chloroquine, they would be negligent,” said Canadian health lawyer Amir Attaran. “When UNICEF does the same,” he added archly, “it’s called ‘international aid.’”179
International capital finally started to mobilize for ACT drugs in the years after 2004. The Global Fund agreed to provide funding for health ministries to purchase the drugs,180 and other drug companies, in partnership with nonprofit aid organizations, started developing alternative ACTs, loosening Novartis’s monopoly.181 The nonprofit Institute of Medicine of the National Academies recommended a new global subsidy, to the tune of $500 million every year, to help pay for ACTs (and future malaria drugs), and international experts started scheduling meetings to explore the possibilities.182 In late 2008, the Global Fund agreed to bankroll a preliminary $6 million for the subsidy.183
When there is a lucrative market to be tapped—say, arthritis sufferers or people with high cholesterol—drug makers can rush a new drug from the lab to the market in under a decade. The system for developing and distributing drugs for public health—to supply to people who earn less than a buck a day—is significantly slower. Between artemisinin’s development in 1972 and the international community’s support in 2004, more than three decades passed. But by then it was arguably already too late.184
Over the decades, while the international community argued and deliberated, the malarious masses grabbed hold of whatever artemisinin they could, and the drug leaked out, in hobbled, diluted forms. Drugmakers seeking to turn a small profit, vendors unable to maintain the drug’s exacting conditions, downright criminals—together they all attenuated artemisinin’s potency against Plasmodium.
In the financial and regulatory vacuum throughout the 1980s and 1990s, an underground market in artemisinin drugs thrived.185 The French company Sanofi-Aventis and Belgian drug makers Arenco and Dafra earned a snappy income selling artemisinin—untethered by a partnered co-drug—across Africa, to those who could afford it.186 Dafra earned $13 million a year doing this.187 Chinese and Vietnamese companies launched a plethora of stand-alone artemisinin drugs, too.188
Exposing the malaria parasite to an artemisinin unfortified with another drug dared the parasite to develop resistance. The barely regulated private channels through which stand-alone artemisinin drugs flowed—the sweltering corner shops and street vendors of Africa and Asia—could not ensure the exacting standards that heat-and humidity-sensitive artemisinin requires. Given the unreliability of electricity and refrigeration, even the most well-manufactured drug can deteriorate by the time it appears on vendors’ shelves in rural Africa. In a study in Nigeria, nearly half of almost six hundred drugs available on the market—antimalarials, antibacterials, and antituberculosis drugs among them—were found to be substandard. Nearly half of the sulfadoxine-pyrimethamine tablets on sale wouldn’t even dissolve in liquid.189
Without the oversight of WHO or local health ministries, drugmakers dreamed up their own dosing instructions. Many of the artemisinin drugs they sold came packaged with recommendations for a five-day course—enough to make the patient feel better, but not enough to kill the parasite190—turning every fevered patient who took the too-short course into a walking incubator for drug-resistant strains. Most alarming of all, the popularity of these drugs spawned a host of even cheaper, and less effective, copies. In 2004, surveyors reported that more than one third of the artemisinin drugs on sale across Asia were downright fakes, pills filled with minuscule quantities of artemisinin, if any.191
The very year that the international community mobilized funds to pay for pricey artemisinin combination drugs, scientists found Plasmodium parasites that could trick artemisinin—at least in mice.192 Just as our own genome spat out multiple mutations when under attack by malaria, the parasite’s genome was mutating rapidly under artemisinin’s onslaught. And some of the mutated parasites displayed a decreased sensitivity to artemisinin. If ACT drugs still killed these parasites, it wouldn’t be for long, the medical journal Lancet noted.193 “Are we losing artemisinin combination therapy already?” the journal asked plaintively.194
The answer, according to a quiet WHO meeting held in Phnom Penh in 2007, had to be a hushed and shaky yes. The gathered experts discussed how, in parts of Thailand and Cambodia—where chloroquine-resistant parasites had first emerged—artemisinin combination drugs were failing in up to 30 percent of cases. The implications of this failure rate—that the parasite had broken through the sole effective drug left in the antimalarial arsenal—the group concluded, “constitute a regional and global emergency.”195
“It will be at least ten years before a drug that good is discovered,” bemoaned WHO’s malaria program director, Arata Kochi, in 2006. “Basically we’re dead.”196
In an unprecedented show of ire, Kochi had already threatened to publicly name and shame the companies if they kept on selling their second-rate artemisinin, and even to disrupt sales of their other products.197 Some companies bristled. The old accusations—drug monopoly—wafted in the air. “Just put the facts on the table,” one Chinese pharma exec pointed out. “The only ACT provider is Novartis. And now you [can] only use ACTs. What do you think?”198 Even after the bigger companies complied with WHO’s demands, nearly two dozen smaller companies with less to lose from WHO sanctions continued to sell artemisinin drugs.199
When the leaders of a small village in rural Myanmar found out that fake artemisinin drugs had led to the death of a local twenty-three-year-old, they ransacked every shop and clinic in the area for its artemisinin supplies. Enraged, they heaped the pills into a towering pile and lit a match. The village gathered for the public bonfire, as the smell of the drug that could have killed malaria filled the air.200
The criminals who sold counterfeit artemisinin drugs remain at large. Despite the efforts of Interpol, only a single counterfeit drug trader, in southern China, has been arrested for selling counterfeit artemisinin.201
The obstacles to our drug war on malaria are not news. Surmounting them occupies perhaps the biggest chunk of time and resources currently spent holding back malaria’s tide. International donors, health ministers, scientists, drugmakers, charities, hospitals, clinicians, community health workers—thousands upon thousands of people on the front lines of the war against malaria devote themselves to getting better drugs to more people. International networks pinpoint the spread of drug-resistant parasites, high-tech labs churn out potential candidates for new malaria drugs, and giant philanthropies work out the details on how to pay for it all. Thousands of experts toil in research labs, clinics, and villages across the globe, burning through hundreds of millions of dollars to do it.
No one can accuse us of lack of diligence in our devotion to the magic-bullet cure, the miracle drug, the wonder pill. And yet, though antimalarial drugs are “one of humanity’s most precious and cost-effective public health resources,” as the nonprofit Medicines for Malaria Venture put it, it’s useful to remember this: even if we somehow got our act together to unleash the full power of our antimalarial drugs upon the malaria parasite, we still wouldn’t win.
Even when we’ve deployed more effective drugs more effectively, the best we’ve been able to do is blow on malaria’s fire. The flames die down, as long as we keep blowing. But as soon as we stop, they leap up, more
vigorous than ever before.
A 1930s effort in Panama rigorously treated all villagers infected with parasites, sick or not, with quinine and other antimalarials. But the more effectively treated the locals were, the less adept their bodies became at fighting off malaria parasites. “Continuous drug therapy results in a lowered immunity,” the scientists explained, “and therefore a predisposition to heavier parasite rates and more frequent clinical manifestations.” The treatment rendered the villagers dangerously vulnerable to the parasites festering in outlying areas, which could contaminate their parasite-free locale. The result, then, would be disastrous. “We fear that more harm than good has been done by this method,” scientists reported.202
In the early 1980s, government officials dosed the entire, nearly two-million-strong population of Nicaragua with a three-day course of chloroquine and primaquine. Reported malaria cases declined for a few months, but within six months, the caseload shot back up to its pre-drug level, and then went on to increase.203
Starting in 2004, Project 523’s Li Guoqiao oversaw the administration of artemisinin combination drugs to more than twenty thousand Cambodians about thirty miles outside of Phnom Penh, and to more than forty thousand on Mohéli Island, one of the Comoros Islands off the coast of East Africa. In Cambodia, parasite levels dropped precipitously, but as close to zero as they fell, the drugs could not extinguish every last parasite. Malaria hung on, its powers of regeneration fully intact.204 On Mohéli, the parasite rate similarly fell, but did not disappear. Even after the vigorous distribution and consumption of thousands of doses, a little over 1 percent of the local people and mosquitoes still harbored the parasite.
The resources required to successfully administer drugs on a mass scale are extraordinary. And yet the best that mass drug administration can do is almost put the fire out.205 Malarious embers smolder on, awaiting their next spark.
6. THE KARMA OF MALARIA
According to studies on risk perception, people are most frightened of unknown risks and least frightened of familiar ones. That’s true even when the unknown risk is minimal and the familiar risk is colossal. Take the neurodegenerative cattle ailment Mad Cow Disease. It affected a few cows in Germany in 2000, and 85 percent of the German public considered it a serious threat to public health. In contrast, cars kill three thousand people every day the world over. We continue to drive them, thoughtlessly and with abandon.1 We take only the most trivial precautions—strapping on a seat belt, perhaps—and even that, to be fair, we do under threat of penalty.
For the people who live with Plasmodium, the risk of malaria isn’t just numbingly familiar. In their lived experience they know that the overwhelming majority of the parasite’s incursions are trivial. Most of the time, carrying the parasite means next to nothing: no fever, no chills, no readily discernible symptoms, especially against a gray backdrop of other, more pressing ailments. It may not even be noticeable. Only seldom does one fall ill. Even then, when illness does occur, ninety-nine out of a hundred times, the fever and chills come and go.
Is it possible that the people who live with malaria consider the parasite the way we consider the sedan in the driveway, as that familiar killer?
This is not an idle question. Most of the ways we’ve devised to destroy malaria rely upon the committed participation of malaria’s victims. It is they who must drain the standing water, swat the mosquitoes, wear the repellent, sleep under the bed nets, go to the clinics, and take the drugs. Their understanding of the disease—what it is, where it comes from, how it can be avoided, whether antimalarial actions are worthwhile—is absolutely crucial, and, in many important ways, as divergent from ours as water is from wine.
The road to Chikwawa, a series of villages in the low valley of the Shire River in southern Malawi, runs down a steep mountainside with dizzying hairpin turns. In every direction tall stalks of corn stand along red dirt tracks. Dusty women with babies strapped to their backs emerge from the green, along with knots of children chewing on corncobs.
When malariologists want to study malaria in its natural habitat, they come here, to Chikwawa. From above, it appears to be one sprawling cornfield, with little clearings of mud brick and thatched-roofed huts scattered within it. Down below, on the rutted tracks, a few bicycles pass by, carrying whole families—man pedaling, woman and child seated behind him—and the occasional pickup crammed with passengers. In the villages—and the small village of Namacha is typical—there’s no electricity or running water, not a shard of plastic or a stick of furniture. There’s a reed granary in the middle of a clearing, a few skinny cows, towering termite mounds. The dominant sounds are the whirring and clicking of birds and insects, and the rustling of the cornstalks. Aside from the international NGOs whose offices line the main road, such as Family Health International, whose blackened building faces the Kuseli Kumrenji coffin Workshop, the clanging racket of modernity is inaudible.2
The subsistence farmers who live here belong to Malawi’s dominant ethnic group, the Chewa. In earlier times, they didn’t stay in these villages for long. They weren’t nomads, but they’d move now and again, leaving lands fallow after the soil was depleted of nutrients. Today, that is no longer possible. Some five hundred thousand people are crammed into this river valley, and they are stuck. Agri-businesses, such as Illovo Sugar, which sits on the edge of Chikwawa, have bought up much of the surplus land, squeezing Malawi’s growing population onto the rest.3
Women with stacks of wood piled on their heads and men pushing antique bikes laden with towers of branches labor up the hill out of the valley. White plastic sacks of charcoal line the roadside. Besides growing corn and other crops, the people of Chikwawa cut down the trees to turn into charcoal. As a result, more and more of the soil washes away with the rains that start in December and don’t stop until May.4 The Mwanza, a once narrow and deep tributary of the Shire that runs through Chikwawa, is now flat and shallow. Every year it floods, blanketing the land with mud and leaving Chikwawa’s village clearings covered with shallow, wet gulleys, ponds, and puddles filmed over with green scum, from which hatch Anopheles gambiae mosquitoes, bestowing the people of Chikwawa with 170 infected bites every year, and malaria that lasts all year round.5
At least that’s how it seems to me.
A small cadre of medical anthropologists make it their business to study how the people who live with malaria think about the disease, and their findings, although seldom referenced by malaria scientists, historians, or policymakers, are riveting. One of the best ethnographic studies on health beliefs was conducted in 1994 by the University of New Mexico’s Deborah Helitzer, who spent eight months living in a Chewa village on the eastern edge of Lake Malombe, about a hundred miles upstream from Chikwawa, interviewing people about malaria. Her findings carry profound implications for humankind’s struggle with the parasite.
Perhaps the most important finding concerns the etiology of malaria. For us, malaria is a disease caused by a protozoan parasite transmitted by mosquito. For the Lake Malombe Chewa, malaria—which the locals call malungo, and lump together with other malaria-like illnesses—is a disease caused by mosquitoes . . . and spirits and jealousy and hexes and bad weather and hard work and dirty water and rotten food, among other things. “This malungo came because I went up the hill to collect firewood,” one Chewa man explained to Helitzer. “I went there two times in a day and this was too much work.” His fever started the following day.6
Anthropologists studying rural people in the Philippines in the late 1990s similarly found a widespread “disbelief ” in the mosquito as the vector of malaria. In Gambia, they found people believed that “close association with cattle” or with certain nomadic peoples caused malaria. In parts of Guatemala, people think malaria is brought on by exposure to cold or wet weather, or by drinking unboiled water.7
Like intelligent design and other forms of magical thinking, these beliefs are not unrelated to actual shortcomings in the scientific explanations with which they compete
. Every time mosquitoes bit Lake Malombe Chewa and they did not fall ill with malungo, their disbelief in the mosquito theory of malaria transmission strengthened. Ditto for every time they took an antimalarial drug and it failed to work. If the drug didn’t work, this meant that the malungo was not caused by mosquitoes.
What these beliefs mean is that while our malaria is an eminently preventable disease, for the Chewa, as for other rural peoples living traditional lives, it is anything but. Malaria is every where, caused by every thing. It always comes, and for people who live in highly endemic places such as Chikwawa, it usually goes, too—like the seasons, the wind, the tide. A Peace Corps volunteer in Chikwawa told me about a deal he worked out, that allowed local merchants to sell mosquito bed nets for around fifty cents. The nets were popular mostly because they repelled pest mosquitoes, not malaria, he said. Eventually, people got tired of the bed nets and used them to catch fish, even as Anopheles gambiae feasted on their children.8
It isn’t that the Chewa villagers don’t understand that destroying mosquitoes’ larval habitats, or sleeping under bed nets, or taking prophylactic drugs, or sealing up their houses, helps prevent malaria. And it isn’t that they aren’t interested in preventing malaria. There are countless accounts of disease prevention in traditional cultures. In traditional Chewa culture, for examples, cattle and people were housed in such a way as to avoid contact with the tsetse fly, and the sleeping sickness it carried.9 The Chewa also allowed soot from their cooking fires to blacken their huts to repel pest insects.10