by Sonia Shah
No, it isn’t that they are not interested in effective fixes. It is that, as with people every where, there’s little interest in fixes that are time-consuming or temporary, or that promise only—in their minds—marginal efficacy. Even if some malungo can be alleviated by people avoiding mosquito bites, they can’t possibly avoid exposure to the weather, or to hard work, or to the envy of their neighbors.11
Partial acceptance of the science of malaria is only one of the differences between our malaria and theirs. In modernized parts of Africa and Asia, most people may embrace the scientific understanding of malaria but still consider the disease the way Westerners consider a headache or a cold or a bout of flu. That is, as no cause for heroic measures. Those who live under endemic malaria do not think of malaria as a killer disease, a predatory wolf to be violently repelled at all costs. For them, it’s more like a stray dog: always around, sometimes annoying, mostly harmless. Among the rural poor, “malaria is perceived . . . as a mild disease,” notes the Institute of Medicine12; a “relatively minor malady,” admits a report from the World Health Organization.13 In a recent survey conducted by Swiss Tropical Institute epidemiologist June Msechu, nearly 60 percent of Tanzanians said they considered malaria a “normal” problem of life.14 Similarly, nearly every Indian relative of mine reacted to my writing this book with mild puzzlement, as if I’d announced I was working on a book about bunions.
When the Lake Malombe Chewa fall ill with malaria they don’t rush to the clinic and hew to the clinician’s every suggestion. They suffer their illness at home. If they decide to take some medication, they’ll choose and buy it themselves from the corner shop. Seventy percent of all the antimalarial drugs distributed in Africa are not doled out by doctors and nurses but sold to patients privately by street vendors, market sellers, and other retailers.15 Buyers take the drug until their symptoms are relieved, and share or save the rest for their next bout.16
For the vast majority of malaria cases, medical care is the exception rather than the rule. This means it is difficult for experts to know how much malaria is occurring, let alone to act as stewards over its treatment. It also means that folk wisdom plays an inordinately large role in how expert-devised antimalarial methods are implemented.
Traditional Chewa people, Helitzer found, judge the efficacy of the medicines they buy based on taste. Because it is chalky tasting, they consider aspirin harmless. Because it is bitter, they see chloroquine—which malaria scientists find to be the very picture of a safe and nontoxic drug—as extremely powerful. If they consider their case of malaria to have derived from some everyday factor—a change in the weather, say, or a hard day’s work—they treat it with only a mild medication, such as aspirin. If they use chloroquine, they use only a tiny bit, because of its perceived great potency. (And they certainly don’t countenance using chloroquine or other antimalarial drugs, many of which are bitter, to prevent malaria.)
Such practices help them conserve antimalarial drugs, for even at the clinic, Helitzer found—in 1994, at the time of her study, as now—there are continual shortages of antimalarial drugs and health workers invariably dole out insufficient quantities to each patient. This of course virtually guarantees that malaria parasites will be regularly exposed to sub-therapeutic doses of the drug. Drug-resistant strains will therefore emerge, and antimalarial drugs will become increasingly ineffective. Malaria will persist. Traditional practices thereby reinforce traditional Chewa people’s assumptions: drugs don’t always work and malaria is a normal part of life.17
One important way malaria kills African children is by causing a complication called cerebral malaria. Helitzer found that the Lake Malombe Chewa clearly distinguished this alarming and often fatal malungo from regular malungo, calling it malungo wa majini. They could accurately pinpoint its symptoms, too: convulsions, fever, and body contortions. They knew that immediate attention from an expert was required, and they were willing to pay large sums of money to get it.
But not at local clinics or health departments.
Even as a child’s fevers turn to convulsions, many rural families avoid the clinic for as long as they can. Malungo wa majini translates literally as “spirit fever,”18 and for traditional Chewa, the proper treatment for spirit fever is a visit to a local traditional healer,19 who holds that cerebral malaria, with its strange, otherworldly symptoms, is the work of angry specters and phantoms.
Eighty percent of Africans use traditional medicines for their illnesses. Traditional medicine isn’t popular because it is cheaper than allopathic medicine—in Malawi, traditional healers charge up to three times more than the local health clinic for their services20—but because the locals consider it more authoritative. Unlike the foreigners and city folk trained in Western-style medical and nursing schools who staff the clinics, traditional healers are rooted in the community. They know their patients, and their patients’ ancestors, and their children, and all their kin. For this, their word on health matters can carry much more weight than that of the allopathic clinicians.21 And they are much more accessible. In traditional Chewa villages, there’s one traditional healer for every thirty or so souls.22
In contrast, the health clinics around Chikwawa, for example, are few and far between. A sick person in Namacha would have to walk over an hour to the district health office, on the main road, and only one villager there appeared to own a bicycle. Getting to Blantyre, and Queen Elizabeth Hospital, would require a formidable fifty-kilometer-long uphill hike into the highlands. Walking it with a sick child or relative would be near impossible save for the most motivated, and none of the people I met seemed to have much if any cash for a seat on one of the crowded, death-defying minibuses that ply the roads. Only the wealthy can afford to drive in cars—the drive from Chikwawa to Blantyre costs the equivalent of twenty-four dollars in gasoline alone.23
In any case, according to a study conducted among villagers in neighboring Tanzania, rural parents consider the quality of care in health clinics to be poor.24 In a study conducted in Senegal, Senegal Research Institute’s Tidiane Ndoye found that local people considered modern clinicians dismissive. They “don’t take time to listen,” Ndoye was told. They always prescribed the same medicine, over and over again, regardless of differences in patients’ temperaments or histories. Because of this perceived rigidity, there was no point in going to see them, Ndoye was told. The sick can just as easily go buy the medicine on their own, from the local vendors, who are generally more flexible about payment than the clinics and hospitals anyway.25
After all, most clinics and hospitals are not like the modern malaria research ward at Queen Elizabeth Hospital. Many more are like the one I saw in Douala, Cameroon. It is a “hospital” in name only; on the Saturday when I visited, there were no doctors, no nurses. There is no door to open or window to pull shut. There is just a crumbling concrete structure of several open-air rooms, with a variety of sick people resting in each, their relatives clutching currency and containers of food and drink. It’s more like a warehouse for the sick than anything else.
That day, two women sat by an unscreened window holding comatose babies glistening with sweat. Both were sick with malaria; for one, this was her twelfth bout with the illness, one episode for each month of her life. Both had been set up with IV drips. Silently their mothers waited in the darkness. The doctor would arrive in two days, on Monday, at which point it could be too late. Every night, the mosquitoes arrived in the hospital. The babies’ arms were rippled with evidence of their bites. This was not a place to escape malaria; it was a place to contract it.
And so, for many rural African families, only after home treatment and traditional healers have failed will they resort to bringing their malarial children to clinics and hospitals. The parents at the malaria ward where Terrie Taylor works exude resignation. Dressed in old T-shirts and wraps, they hover over their children’s cribs, exhausted, teary-eyed, and silent, clutching faded pink booklets containing handwritten notes from each clinician
who has tended to their children. They rarely ask questions.26
According to WHO, cerebral malaria should be treated as rapidly as possible, with an injection of quinine and a shot of anticonvulsants. But by the time cases of cerebral malaria arrive in a clinic it is often too late to reverse the course of the disease. The encounter between patient and clinician is ill-fated from the start. If the result is poor, for the patient and her family, the clinic is seen as the option of last resort, the place where you take your child to die.27 For the clinicians, battered by the sickest cases, malaria is revealed as a dire villain that must be defied at all costs. Malaria thus takes the lives of many hundreds of thousands of children, and the two worlds, like two unmoored rafts, drift farther apart.28
As with HIV and cancer patients, many malaria patients live sufficiently long with their disease to be able to exert political pressure on their leaders. HIV-infected people and cancer patients organize marches, staffphone banks, and write letters demanding more research, more funding, more and better treatments. Malaria sufferers, by and large, do not. Because there is no built-in political constituency for malaria, and because malarious nations are generally poor anyway, their government leaders do not generally allocate much political capital to fighting the disease.
Thus, despite the vibrancy of malaria and its shocking death toll, in many malaria-endemic countries there’s little political urgency about it. Health authorities can’t help but echo the detachment of their constituencies. In 2006 I visited with the Panamanian government’s top scientific advisors on tropical diseases, at the Gorgas Memorial Institute, shortly after the Chepo outbreak. Dr. Jorge Motta, director of the institute, told me on the phone and by e-mail that he was far too busy to meet with me, which seemed understandable, given the circumstances. Malaria had quadrupled in Panama, and drug-resistant parasites were creeping toward the capital, a stone’s throw from the towering cargo ships that ferry through its canal. I imagined a crush of epidemiological surveys, labs overflowing with blood samples, calls to be fielded from neighboring towns and cities, reports to be filed, and presentations to be made at international gatherings. Of course he was too busy to meet with me.
But when I visited the institute to interview his less-busy underlings, I found the place the picture of inactivity. Motta graciously ushered me into his spacious office. The large conference table was bare and glistening. Some staff members and visitors sat around it, alternately chatting, reclining, and flipping through magazines. Motta ambled in and out, telling jokes. Later in the day, when I poked my head in a couple of times, the scene remained unchanged. At one point, someone wandered in with a few plates of hot snacks. When I left they were still there shooting the breeze.29
Anyone who has worked with health authorities in malaria-endemic countries will recognize the pattern. Noises are made about the urgency of the malaria problem, the travesty of thousands dying from mosquito bites—and then the sleepwalker returns to bed. In West Africa, health ministers hold lavish meetings with celebrities and corporate sponsors to announce new malaria initiatives. Malaria is a serious problem, they say. They will work harder to fight it, they say. Then the electricity cuts out and the lights dim. The air-conditioning whirs to a halt. The ministers drone on with their speeches, and the journalists lean farther back into their chairs. They adjust their weight, tip their chins into their chests, and nod off.
Most clinicians in endemic countries consider malaria a fairly boring field in which to practice. One might guess that among doctors and nurses in Malawi, for example, malaria would have the stature that heart disease or cancer has in the West. But local doctors, even at hospitals such as Queen Elizabeth, where cutting-edge malaria research takes place, misunderstand the basic contours of the disease and its toll on the population. Malaria may be a “mild” illness in many people, but the fact that it makes sufferers more vulnerable to other diseases has been known since the early twentieth century, when British malariologists in Malaysia found that mortality from all causes plummeted after they disrupted malaria transmission. Malaria’s broad effect on overall mortality has been a cornerstone of efforts to tackle the disease.30 And yet, when this point came up during a short lecture at Queen Elizabeth Hospital in 2007, the local doctors professed disbelief. They questioned the concept of a malaria prevention method called intermittent preventive treatment, which has been popular in malaria circles since at least 2004.31 This was as jarring as it would have been to hear clinicians at, say, Massachusetts General Hospital dispute the burden of heart disease, and say they hadn’t heard about the preventive effect of daily aspirin to ward it off.
Even the hardworking nurses in Queen Elizabeth’s malaria research ward, who spend their days tending to the torrent of malaria-plagued kids who flow through the ward, seemed to have little interest in the basic facts of malaria transmission. Gathered in a cramped lounge for afternoon tea in 2007, the nurses swung their legs over the edge of a twin bed covered in faded green blankets, which they used as a couch. They seemed bored by my questions in English, which made them go silent. Nevertheless, I asked them where the culprit, Anopheles gambiae, came from. After a long pause, one said, with some finality, “the swamp.” They all nodded. According to the medical entomologist I later spoke to, A. gambiae specialize in Blantyre’s clear, sunny puddles.32
There’s a serious dearth of African clinicians specifically trained in malaria. Western donors have launched special programs to entice more Africans into the field, with scholarships and grants for study at Western universities. Trouble is, once they get the special training, they can get a job anywhere in the world. Few are willing to take the pay cut to go back to malaria territory. To entice foreign-trained Malawian clinicians to practice in Malawi, Queen Elizabeth Hospital must offer starting salaries that dwarf those of its most senior staff. It’s a high price to pay, yet still there are rarely enough clinicians to tend all of the hospital’s sick.
Most malaria deaths occur well outside the official medical system, so like a whale under the sea, Plasmodium’s true reach remains maddeningly elusive. WHO estimates that at least 60 percent of malaria cases in Africa, and 80 percent of malaria deaths, go unreported.33 Even under the watchful eyes of some of the most highly trained malariologists in the world, malaria rides under the radar. Such a common criminal, near ubiquitous, should be easy to diagnose, but it isn’t. The gold standard for diagnosing malaria is by microscopic examination of the blood. This takes time, training, and resources—and it is not easy. Technology that can diagnose malaria more simply has been developed, but it has yet to be widely disseminated. In the meantime, a trained technician must scrutinize a thick film of blood smeared across a slide, and because the parasite may lurk in just a few cells, the technician must hunt for it in one hundred different sections of the slide, adjusting the scope for each one. To pinpoint the parasite species, another, thinner smear of blood must be prepared, so that the microscopist can see the subtle morphological differences that distinguish P. vivax from P. falciparum from P. ovale.34 Since parasite levels vary over the course of an infection, this must be done several times over several days to accurately establish the fact of an infection.35 And even this may not be sufficient to catch every infection. Using polymerase chain reaction (PCR), scientists can amplify and discern tiny fragments of parasite DNA. In one study in Senegal, two thirds of children whose blood, under microscopic scrutiny, appeared parasite-free were in fact harboring falciparum parasites as discerned by PCR.36
The other problem in collaring malaria is that the innocent look the same as the guilty: the blood of a healthy carrier of malaria parasites is indistinguishable from the blood of a mortally infected one. And so while microscopic diagnosis can show that someone has malaria parasites in his body, it can’t pinpoint whether that person is sick from malaria parasites. Indeed, there’s evidence to suggest that even the most experienced clinicians, using both clinical and microscopic diagnoses, mistakenly see malaria when some other pathogen is the true
culprit. One out of four patients believed to have died of malaria in Terrie Taylor’s malaria ward turns out, upon autopsy, to have no malarial pathology capable of causing death. There are no infected cells sequestered in the brain. The patient had malaria, surely, but died of something else entirely.37
So how do clinics without the benefit of well-stocked labs, steady electricity, well-maintained equipment, or trained personnel—some don’t even have thermometers—figure out if someone has malaria? The simple answer is that they don’t. Given a widespread sense of malaria’s ubiquity, and the potentially grave consequences should a bona fide case of falciparum infection go untreated, standard procedure calls for “presumptive diagnosis.” That is, if there’s a fever, presume malaria and dole out the antimalarial tablets and shots.38
And so along with a high level of underreporting, there is a high level of overreporting. Nevertheless, statistics are duly gathered. In the mid-twentieth century, the malariologist Leonard Bruce-Chwatt estimated that roughly one million Africans die of malaria every year. Governments, international agencies, aid organizations, and the news media have basically stuck to that assessment. A team from Oxford University, using risk mapping and analyzing a compilation of studies, reports, and unpublished records, estimated 1.1 million malaria deaths in Africa in 2000. In 2001, WHO estimated 1.1 million malaria deaths worldwide, with 970,000 malaria deaths in Africa.39
When, in 2008, WHO adjusted its assessment of malaria cases downward, slashing the figure in half, and reducing its estimate of malaria deaths by more than 20 percent, many experts simply shrugged their shoulders. They knew, as WHO said, that nothing had really changed on the ground. “It’s better fudging,” said one. But “it’s still assumption built on assumption built on assumption.” Even a “back-of-the-envelope calculation,” a prominent malaria epidemiologist added, would render more accurate numbers.40