The Fever: How Malaria Has Ruled Humankind for 500,000 Years (32 page)

Multimillion-dollar checks went out to WHO, PAHO, and those countries willing to convert their malaria-control programs into eradication programs.
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The developing world’s biggest campaign was launched in India, with $38 million from the United States and $50 million from the national government.
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Ninety-two other malarious countries devoted themselves to the eradication cause, with several allocating as much as 35 percent of their tiny public health budgets to sending teams of workers into the field, canisters of DDT tied onto their backs.
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Between 1957 and 1963, the United States would spend $490 million on the campaign, its single largest contributor.
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For the first few years, the global malaria-eradication program was every thing Paul Russell and IDAB said it would be. By 1960, eleven countries had banished malaria from their borders, and a dozen or more had sent malaria rates plummeting.
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Cases across Central America and in demonstration villages in Papua New Guinea fell to negligible levels.
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In India, an annual caseload of seventy-five million dropped to fewer than one hundred thousand.
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In Borneo, the parasite rate fell from 35.6 percent to less than 2.0 percent.
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Newly malaria-free populations were as beasts of burden relieved
of their loads. Life expectancy in Sri Lanka increased from forty-three to fifty-seven years, and the prime minister envisioned repopulating the uncultivable malarious parts of the island. Life expectancy in Sardinia increased from 30 percent below national rates in Italy to 3 percent above.
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Rice cultivation increased tenfold in Greece, Morocco, and Indonesia. In Cambodia, land values doubled.
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According to the experts, it was only a matter of time before the disease would be no more and these gains secured for all time. “If such a degree of control can be obtained” as quickly as it had been in so many places, WHO reported, “complete eradication can be expected in the near future.”
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Showered with honors as the Man Who Ended Malaria, Paul Russell watched the proceedings from a new position at Harvard University, confident in an imminent victory.
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Across Europe and North America, tropical medicine departments closed their doors. What was the point of furrowing brows over a soon-to-be-extinct disease? The study of how insects transmit malaria and other diseases became “a dead field,” said a Johns Hopkins malariologist. “DDT is killing it.”
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Malariologists drifted into other, more well-funded fields, and new young scientists did the same.
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The nuanced, multidisciplinary field, enlisting the insights of engineers, entomologists, ecologists, clinicians, and anthropologists, had devolved into a single brute question: how to coat interior walls with two grams of chemical per square foot.
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Even before eradicating malaria, the joke went, the campaign eradicated malariologists.

The spraying continued.

According to the IDAB plan, every single domicile in the program had to be sprayed with DDT twice a year for at least four years. Across the globe, teams of workers appeared in villages and towns toting large canisters of strange-smelling chemicals. They demanded that residents leave their homes, and take all their food and eating utensils with them. They removed all the pictures from the walls and
moved the furniture around, leaving the walls covered with a powdery residue. It smelled like chlorine.

Locals found that the DDT didn’t just repel and poison
Anopheles
mosquitoes and the pesky houseflies and bedbugs. It killed their chickens, too, and, in Malaysia, the flies that parasitized the caterpillars that fed on thatched roofs. Not long after DDT spray teams left, the village roofs collapsed.
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In Borneo, the DDT killed the cockroaches, which killed the cats that ate the cockroaches. The cat-free villages were left with a rampaging rat population, and their crop-destroying, disease-carrying ways.
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For all this and more, suspicion reigned. In North Vietnam, local revolutionaries suspected that the spray teams were somehow collecting military information with their strange equipment. Villagers feared that evil spirits would enter their huts through the small holes campaign staff had made to install mosquito-catching traps.
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Buddhist leaders in Cambodia and earlier nonviolent leaders such as Mohandas Gandhi in India objected that the campaign offended their religious sensibilities.
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The benefits of malaria eradication would likely have outweighed many of these admitted downsides, but there’d never been any attempt to enlist the support of the malarious masses for the DDT campaign. From the beginning, the program had been a top-down affair, hatched, funded, and overseen by experts in distant lands. The residents whose homes would be doused with DDT had barely been asked for permission.

Even after suspicions and objections arose, campaign leaders did not call for a massive public education push or for greater local participation in the conduct of the campaign. Instead, they practiced damage control. In Borneo, WHO opened special centers to collect donations of new, healthy cats. In the most remote areas, it arranged for the Royal Air Force to air-drop, along with vegetable seeds and “4 cartons of stout for a recuperating chieftain,” twenty cats ensconced in specially devised cat baskets.
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(“Many thanks to R.A.F.,” wrote one local, “also to cat donors and cat basket makers . . . very accurate
dropping.”)
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In Vietnam, they organized soldiers to accompany the spray teams for protection.
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To Gandhi and the Buddhists, they offered the following bit of convoluted logic: Nobody was forcing DDT upon the mosquito. “If she chose to break into his home to drink his blood,” as one campaign malariologist said to Gandhi, “and died in the course of her trespass, that was her doing, not his.”
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None of this proved particularly persuasive. “Operation Cat-Drop,” as one bemused local called it, earned the lasting mockery of environmentalists every where (thanks in part to a fictionalized version of the story by the novelist T. C. Boyle).
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Far from being reassured by the presence of troops, Vietnamese villagers groused that the DDT spraying was being forced upon them.

Before long, spray teams around the globe found themselves in villages where no one was home and every door locked. In India, fewer than one in nine spray teams adequately sprayed their assigned areas. In a village of sixty-three houses, ten doors would be locked, thirty-five residents would refuse access, and one house would be forgotten by the spray team. Of them all, only seventeen houses would be sprayed.
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Growing recalcitrance of the public took its toll on the morale of the spray teams themselves. Some started taking bribes from those who wanted their homes spared. Others grew weary of carrying their tanks around all day, and so doubled their morning spraying so they could rest in the afternoon. Still others sold their DDT on the black market, spraying homes with a worthless dilution instead.
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As the spraying stumbled, so did the business of surveillance. Surveillance was both a much bigger job than spraying, requiring more resources and infrastructure, and much more hidden from public view. Teams of workers had to go door to door, collecting blood samples and actively hunting for fever cases. Each slide of blood had to be meticulously examined for parasites, and if any were found, workers had to go back out and find and treat the host. Mosquitoes had to
be collected and their susceptibility to DDT tracked. Few countries had the skilled workers, clinics, or support systems required.

Surveillance workers skipped remote and hard-to-reach villages and took extra blood samples from more accessible residents instead. Back in the labs, there’d be two-and three-month backlogs of unexamined blood slides towering over microscopists.
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Meanwhile, the
Anopheles
mosquito, having escaped the attention of antimalarial spray teams, continued to be exposed to low levels of the insecticide on DDT-doused crops, and its populations were growing increasingly tolerant of the toxin.

DDT use in agriculture, especially in developing countries, soared. International development experts pushed for more DDT coverage on the rice and cotton fields of the developing world, convinced that this would unleash the massive harvests required to end hunger and poverty. In 1952, American chemical companies sold twenty-five million pounds of DDT overseas. Over the following decades, its exportation more than tripled.
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Mosquitoes alit on the DDT-dusted vegetation, and in the DDT-contaminated streams and puddles, they laid their eggs. And what didn’t kill them only made them stronger.

Solving these myriad problems required innovative, locally sensitive solutions, but with malariology all but dead, WHO was forced to dispense increasingly equivocal advice. Remembers the organization’s José Nájera, “A solution was sought in oversimplification and standardization.”
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WHO soft-pedaled the spread of insecticide-resistant mosquitoes, urging the spray teams to continue. In 1962, it claimed that resistant mosquitoes “in no case” put the prospect of eradication “in jeopardy.”
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(The Royal Society of Tropical Medicine and Hygiene reached the opposite conclusion that same year, claiming that resistant mosquitoes were “seriously interfering with progress” in the
campaign.)
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In 1970, WHO allowed that resistant mosquitoes challenged the outcome of eradication in a few countries, but called the problem “more of an inconvenience than a major obstacle.”
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In 1973, WHO advised countries to continue spraying—but to use more expensive alternatives instead.
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And the organization rubber-stamped mass medication programs. In Brazil, antimalaria leaders confiscated supplies of table salt from all commercial establishments and homes, replacing it with salt loaded with fifty milligrams of chloroquine per gram.
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With WHO’s blessing, leaders in Angola, Cambodia, French Guiana, Ghana, Guyana, Indonesia, Iran, Irian Jaya, the Philippines, Sarawak, Suriname, and Tanzania followed suit. Millions of people around the globe, whether infected or not, regularly drugged themselves with their daily bread.
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In most places, it took about six months of mass medication to trigger the emergence of drug-resistant parasites, sending malaria rates back up to their pre-medicated-salt levels.
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The United States’s five-year funding commitment for the malaria eradication campaign came to a close in 1963.

Globally, annual malaria cases had fallen from 350 million to 100 million, a historic low, but every where one looked, poverty and malnourishment and instability still reigned.
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Paul Russell and IDAB had claimed that malaria’s demise would lead to greater prosperity and more land in cultivation, but when WHO hired an economist to describe just how, according to the historian Randall Packard, “no one was able to provide the data he needed.”
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What Russell and IDAB hadn’t figured on was the countereffect of rising numbers of surviving people. In Western countries, where malaria receded with the onset of industrial development, declining death rates were matched by declining birth rates. But when malaria was surgically excised from countries sprayed with DDT and other
chemicals—leaving intact the unelectrified shacks and the landless peasants who lived in them—the result was quite different.

In Sri Lanka, for example, the population grew by over 3 percent a year between 1921 and 1975; the University of Michigan public health expert Peter Newman attributed as much as 60 percent of this growth to falling death rates thanks to the malaria-eradication effort. But birth rates did not decline, and the growing population, demanding food, medicine, and education, soon outstripped the modest gains in economic growth that malaria’s decline had unleashed. As scholars pointed out, death rates had modernized, but birth rates remained ancient.

On Sardinia, the lives of the locals lengthened, but agricultural productivity and economic production continued a steady decline that had begun in the 1940s. Wealthy outsiders rented summer residences on the newly malaria-free island, but tourism didn’t enrich the local Sards, many of whom fled the island in search of temporary jobs elsewhere.
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“Their lot in life had improved little,” writes the historian John Farley, “and only noncritical tourists wearing blinders could call what had happened progress . . . Tourists have certainly replaced mosquito vectors in Sardinia but the indigenous population remain second-class citizens.”
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The medical anthropologist Peter Brown calls the transformation of Sardinia “modernization without development.”
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At the same time, the political calculus that set the funding stream aflow had shifted. In the United States, enthusiasm for bold chemical attacks on pestilence started to give way to fears of poisoning and overpopulation. By the 1960s, public health experts had reached a new consensus, that the most serious problem facing humanity was not excess death from disease, but just the opposite: overpopulation.
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Under the new way of thinking, less malaria didn’t mean more people to produce more food; it meant more people to eat food and use up scarce resources. Saving people from sickness just condemned them to death by starvation.
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Wasn’t malaria really a “blessing in disguise,”
the naturalist William Vogt posited, since “the malaria belt is not suited for agriculture, and the disease has helped to keep man from destroying it”?
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Indeed, the United Nations’ Food and Agriculture Organization’s first world food survey, published in 1946, had laid blame for the malnourishment of over half the world’s population on the decline in mortality from infectious disease.
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As public apprehension grew, malaria eradicationists found themselves under attack for their shortsightedness.
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Critics attacked Russell as a “dangerous doctor” whose ideas were “creating problems faster than they are solving them,” as Russell put it.
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