THE FEVER

Reviewed 10/30/2013

The Fever, by Sonia Shah

THE FEVER
How Malaria Has Ruled Humankind for 500,000 Years
Sonia Shah
New York: Farrar, Straus & Giroux, June 2010

Rating:

5.0

High

ISBN-13 978-0-312-57301-0
ISBN-10: 0-312-57301-4 308pp. SC $16.00

The scourge of malaria has been with humankind since humankind existed. A remarkably adaptable parasite, the organism that causes malaria has defeated everything we have thrown at it, from time-honored, natural remedies like cinchona (quinine) through the drugs chloroquine and artemisinin, the newest in our armamentarium. They work for a short time — a year or two — then stop working.1

These days, mosquitoes infect between 250 million and 500 million people with malaria every year, and close to 1 million perish. Equally shocking is the length of malaria's tenure upon us. Humans have suffered the disease for more than 500,000 years. And not only does it still plague us, but it has become even more lethal. That's quite a feat for a disease we've known how to prevent and cure for more than a hundred years. During that same time, we've vanquished any number of similarly once-commanding pathogens, from smallpox to the plague, and have come to expect nearly complete control over newer pathogens, such as SARS or avian flu. The few that slip through our fingers, such as HIV, are the rightful subjects of anguish and soul-searching.

Yet despite the fact that we've known about malaria since ancient times, and have the drugs, killing chemicals, and know-how to avoid it, something about this disease still short-circuits our weaponry.

– Page 9

Among the factors that have complicated the quest to understand and eradicate malaria are:

A Pig Under Every Bed

In America and Britain, malaria was eradicated largely by economic development and the demographic changes that resulted. Plentiful coal resources permitted steam engines powering irrigation pumps, continent-spanning railroads, and other artifacts of the industrial revolution. Soon the water wheels and irrigation canals had disappeared. Swamps were turned into farmland, removing mosquito breeding places. The "skeeters" that remained found the burgeoning numbers of livestock — cows, sheep and pigs — more attractive than human flesh, and plasmodium could not live in these four-footed hosts. Hence the partly tongue-in-cheek recommendation to have "a pig under every bed."

In addition, the growth of manufacturing and public transportation meant people could more easily move north to jobs in the fast-growing cities. These factors, more than intentional mosquito abatement and antimalarial medicines, swept the disease away.

Against these confounding factors can be set the basic fact that malaria severely saps the initiative of populations to which it is endemic. Where it has been eliminated from such populations, the incidence of many other debilitating diseases also plummets. Africa would certainly be happier and more productive today without malaria, filariasis, dengue fever, sleeping sickness, and the other endemic diseases that currently burden it.2

Thus, the purely humanitarian merit of preventing death and suffering is augmented by practical benefits. It is to be hoped that Western countries can mount a sustained effort against such maladies. It would surely repay their investment even without the likely prospect that tropical diseases will spread toward the poles as the world warms during this century.

Unfortunately, as the author makes abundantly clear, developed nations today are as unable to commit to and carry out long-term antimalarial programs as they were in the past — and for similar reasons. Subject to competing demands for spending and shortsighted political processes, funding for malaria control is fickle. Different groups push their own, often conflicting strategies.3 They cannot all be correct; when the wrong strategy prevails, eradication fails. Most important, intervenors from Western nations typically do not take the time to understand and involve the people they are treating. And that is what it will take to eradicate malaria, or even to control it.

While we debate, and argue, and haphazardly collect our strength to fight malaria, the parasite refines its plague upon us. Unlike us, Plasmodium does not reenact failed strategies and weak defenses, its historical memory shot. The evolution of its predation is progressive, methodical, probing.

– Page 239

Sonia Shah, an investigative journalist born in New York City to parents from India, has two previous books to her credit: The Body Hunters: Testing New Drugs on the World's Poorest Patients and Crude: The Story of Oil. This book demonstrates prodigious investigation and conveys a sweeping historical view of our progress — a haphazard progress, to be sure — against the mosquito-borne malady. Much like Elizabeth Kolbert in Field Notes from a Catastrophe, Shah mixes statistical data with personal stories, making The Fever an engrossing read. A diagram of the Plasmodium parasite's life cycle follows the text. There are plentiful endnotes and a very good index. Shah makes some grammatical errors and repeats two annoying vocabulary substitutions: "healthful" for "healthy," and "broach" when "breach" is the right word. I list these in my Errata page. These errors are inconsequential, taking nothing away from the value of this book. I give it top marks and rate it a keeper.

1 This is not completely accurate with respect to the last drug. Artemisinin combination therapy (ACT) uses two drugs and is recommended by WHO as the first line of defense against malaria. But it costs ten to twenty times as much as other antimalarials. Donors balked at supporting distribution, and aid organizations fell back on cheaper drugs like chloroquine. The author quotes Canadian health lawyer Amir Attaran: "If a physician went to Burma and prescribed chloroquine, they would be negligent. When UNICEF does the same, it's called 'international aid'." (See pages 115-16.)
2 The author cites an article by Jeffrey Sachs (Time, 2007) estimating that Africa loses $12 billion per year due to malaria. (See page 230.)
3 The World Health Organization (WHO) does not recommend a therapy called IPTI for use against malaria. The Gates Foundation, however, has invested much research funding into IPTI and asked for a separate review by the U.S. National Academy of Sciences. That review agreed with WHO's conclusions but nevertheless declared IPTI worthwhile. (See pages 234-5)
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