Every year the United States spends hundreds of millions of dollars to control the fertility of the developing world’s people. Every year at least 2.7 million of those people1 — or about one every 12 seconds2 — (of whom an estimated one-third are under the age of five) dies of malaria, a disease whose origins, methods of treatment and courses of prevention mankind has known or studied for 100 years. That these two facts co-exist represents one of the greatest scandals in American foreign policy during this century and threatens to poison US relations with many nations in the developing world well into the next.
What is malaria?
Malaria is among the best known of human parasitic diseases. Its infective cycle begins when a female mosquito belonging to the genus Anopheles bites someone already carrying one of four species of protozoan parasites belonging to the Plasmodium family, Along with the blood she ingests come tiny malarial cells called gametocytes. These migrate to the mosquito’s mid gut where, over a period of about 12 days, they sexually produce sporozoites, which are the cells responsible for infecting humans and which migrate to the mosquito’s salivary glands. When the malarial infected mosquito bites a new host large numbers of the sporozoites mingle with her saliva and enter the person’s bloodstream, where they move quickly to infect liver cells. There, over about 10 days, they reproduce and mature into cells called merozoites. These, in turn, reenter the bloodstream, where they infect and kill red blood cells by appropriating the host cell ‘s critical hemoglobin for their own asexual reproduction and then massively infect other cells. This final stage of the cycle includes the fever, shakes, anemia and other symptoms that characterize malaria, and it is here that the protozoa produce more of the gametocytes to await introduction into a new mosquito.
Although the differences between the species of Plasmodium appear relatively minor, their disease impact is not. P. falciparum is widely held to be both the most dangerous of the four and, tragically, the one most resistant to the current range of anti-malarial drugs. Almost alone among the four, falciparum has the ability to alter the surfaces of the blood cells it infects so that, even if only merely infected, they adhere to the walls of their surrounding blood vessels and lead to clots and other complications associated with the dreaded cerebral malaria.3 Falciparum is also known for attacking incredibly swiftly once it reaches the final stage. “It is not unheard of for an African child to go to school in the morning and die of falciparum infection in the afternoon,”4 writes Ellen Shell in the August 1997 issue of the Atlantic Monthly, noting that this fact should put the public’s recent fascination with the Ebola and other rapidly acting microbes into greater perspective. “The 1995 Ebola outbreak in Zaire that inspired Hollywood and transfixed the world caused approximately 250 deaths over a period of six months. More than twenty times that many Africans die every day from malaria,”5 Shell writes.
Almost every nation in the world is at some risk of malaria, but the disease is endemic primarily to Africa and a further eight nations outside of Africa. According to the World Health Organization (WHO) roughly 40% of the world’s population in 1992, or over 2 billion people, must be considered “at risk” for malaria as they live in one of the 90 countries or territories where the disease is considered endemic. There are, conservatively, between 300 to 500 million confirmed clinical cases of malaria in the world each year with an unknown additional number unreported or unrecognized. Malaria alone accounts for between 10% and 30% of all hospital admissions for children under the age of five in Africa, and for between 15% and 25% of all their deaths.6 Total cost estimates for malaria in Africa alone, including costs of treatment, prevention, and lost productivity, were estimated to be 1.8 billion US dollars by 1995.7
Malaria’s medical burden
Unlike other diseases, such as HIV and tuberculosis, whose costs must usually be measured in deaths, malaria’s price must be looked at differently. Malaria differs from HIV and tuberculosis in that it does not kill everyone who contracts it, even if left untreated. In fact, if someone lives in an endemic area and has survived infection by the age of five, many in the public health field would consider him “immune” from the disease. But “immunity” from malaria does not mean the same thing as “immunity” from other diseases. In the developed world, when someone either contracts an illness or accepts a vaccination he or she is said to be “immune,” which is understood to mean that their body will not allow them to become sick with the same illness a second time. But “immunity” in malarial terms means not that the body has rid itself of the parasite and will not accept it again, but that the body and the parasite have achieved a sort of “compromise.” The patient will not be totally rid of it, but it will not kill you, at least directly. Being ‘“immune” from malaria in an endemically infected region actually means being periodically assaulted by the disease — but always left alive enough to recover and play host for the next parasitical round as long as the patient’s weakened state does not cause him to die from something else first.
In theory this might seem an ‘“acceptable” situation. At the very least it is the situation that has persisted in African and other endemic regions for hundreds of years. But in practice the consequences are horrific, and particularly so for nations that are underdeveloped already.
Consider that every malarial attack means thousands of parasites sucking as much as a quarter pound of hemoglobin out of an infected person’s cells in a matter of hours.8 In first-world terms this is the equivalent of a significant blood donation. But malaria, unlike the Red Cross, does no weight, health or other screening. Everyone, even small children, lose vital red blood cells whether they can afford to or not. And many lose them at such a frequency that they rarely get a chance to fully recover and are thus continually anemic. Bernard Nathan, a physician working with malarial patients in Kenya, reports that “one in twenty” children in the villages surrounding his clinic are so anemic that “if their blood were tested in the United States they would be rushed to a hospital for emergency transfusions.”9
The effects are even more dramatic when seen under a microscope. Ellen Shell writes of seeing “greatly enlarged photographs” which capture malaria parasites “pouring from the ghostly white hulks of dead blood cells like soldiers fleeing a scorched earth spree.”10 This, she writes, not only leads to the characteristic anemia, but also, with falciparum, to the cerebral malaria which takes its toll most horribly on children. In one clinic near Dakar, Senegal, she found that every child admitted was under treatment for cerebral malaria. The “full-blown cases” she described as looking “terrible.” “Their eyes were unfocused under half-closed lids, and they lay absolutely still. Scientists aren’t sure, but they believe that cerebral malaria causes brain damage in about 10 percent of cases and it is estimated that an additional l0 to 50 percent of cases result in death.”11 But even this, like most malaria, remains treatable if reached in time.
Malaria’s medical impact on the developing world is such that it must be considered in almost every aspect of a nation’s overall health – including those which receive a lot of media attention in the west. Or for example, a geographic analysis of the distribution of the alleged 600,000 maternal mortality deaths which have been subject of at least one concerted press campaign — suggests that more than a third of these can be attributed to complications from malaria, particularly among women entering pregnancy already anemic. In addition, 20 to 40 percent of babies born in endemically malarial regions come into the world with low birth weight, an average of 469 grams lower than average in one study,12 which is a risk factor for later diseases and death.
Shell writes: “A study recently conducted in the Gambia suggests that almost any estimate of malarial deaths woefully underestimates the impact of the disease, because the control of malaria seems to bring about a radical reduction of mortality from all causes.”
Malaria’s economic burden
The extent of malaria’s economic burden are obvious when one considers what trying to live in a state of near perpetual anemia must be like. WHO estimates that every bout of malaria costs ten lost workdays,13 but other estimates range even higher and include more detail. Using the more thorough “disability-adjusted life years” (DALY’s) to measure malaria’s disease burden, for example, led the World Bank in 1993 to estimate that malaria cost the continent 320,000 years of lost productivity, life and health in 1990. Using the DALY measure, Africa is the only continent where tuberculosis and other pulmonary infections were displaced as the leading cause of lost health, bounced into the number two position by malaria.14
The impact this has on daily African work and life cannot be overestimated. Patrick Duffy, a physician working in Kenya, reports that when he has treated Africans with the drugs necessary to clear their blood — even temporarily — of the malarial parasites the patients report feeling “as they never have before — that is to say, well.”15
Other anecdotal evidence is equally telling. Shell reports visiting a village in Senegal where elders of the village indicated they have suffered from malarial bouts several times during the season, where the men report losing “two to three weeks a year” to the disease, and where all report being tired most of the time. Indeed, malaria’s impact on the human resources of an economy are such that the medical and economic impacts severely overlap. For example, studies in Kenya and Nigeria have estimated the malarial impact at between two and six percent of Kenya’s entire gross domestic product (GDP) and between one and five percent of Nigeria’s.16 By comparison, the United States’ entire national debt is estimated to be about five percent of the GDP.
At the household level the economic impact is even more telling, with estimates from Malawi placing the cost at between four and 28% of monthly household income. Kenyan costs were estimated at between nine and 13%.17
The costs rise even higher when considered as a burden on future human resources. In 1994, children under five in Tanzania experienced one acute attack of malaria, on average, every 10 months. In hyperendemic regions of the country a child could expect to fall acutely ill to malaria between nine and 11 times by the time he or she reaches five years of age, if he or she lives that long.18
Situation growing worse
Although numbers are sketchy and hard to come by, the general consensus among epidemiologists and public health officials seems to be that the world’s malarial problem is growing worse.
One close study of published data found that malaria, across Africa, accounts for 40% of fever cases and up to 24% of fevers that end in death. Even though only between eight and 25% of Africans with malaria were actually able to go to a doctor for their illness, malarial cases still accounted for between 25% and 50% of all admissions to African health services. The growth in the number of malaria cases across the continent ranged from a “low” of 7.9% to 21.0%.19 In Zambia, cases per 1000 people have risen from 167.5 in 1982 to 355.7 in 1994.20 That means that, in a given year, 1 in 3 Zambians will fall acutely ill to malaria, which is not surprising since 76% of the rural population is thought to be infected.21
What is to be done?
Essentially, the research evidence suggests that mankind has been living in a borrowed century when it comes to malaria, and those 100 years are about to run out. Specifically, there can be little doubt that the Plasmodium parasites that cause malaria have achieved ever-increasing degrees of drug resistance and that research on new drugs, or on new methods of mosquito control, has ground to a virtual halt. Still, there are measures that can be taken to better control malaria’s devastation and render even more territory malaria free or almost malaria free.
First, in the area of drugs, there are indications that significant progress can be made toward developing a vaccine against malaria, or at least against its most common and deadly forms. In a November 1996 report, the Committee on Malarial Vaccines reported to the National Academy of Sciences’ Institute of Medicine that a malarial vaccine is “feasible” and that the primary research is falling into place.22
The Committee’s report called on the US Government to create a Malaria Vaccine Development Board, modeled on the 1941 Commission on Influenza in the Armed Forces and the National Task Force on AIDS Drug Development. This board would coordinate public and private efforts so that research could be both available to all and still proprietary to a company that might be interested in marketing a malarial vaccine worldwide. Although the Committee pointed out that significant scientific and logistic hurdles remain, success in discovering a malarial vaccine would not be without precedent.
Second, different avenues of mosquito control need to be explored and made more available to people in hyperendemic regions. If we cannot protect human blood from the Plasmodium protozoa, we can do a better job protecting human beings from the mosquitoes that carry the parasite. Two new approaches to mosquito control hold promise and deserve to be funded more fully. The first uses nets permeated with an effective insecticide that drives away or kills mosquitoes before they can get close enough to bite.23 Although dipping the nets in a pyrethroid emulsion every 6-12 months has been proven to reduce biting incidence without placing the people sleeping at risk, the nets are not perfect. Often they are not hung correctly, or they block the evening breeze which reduces comfort in the tropics. Also, mosquitoes do not only bite people in bed.24
The second avenue attacks the mosquitoes at a different part of their life cycle, when they are still in the larval or pupae stages and in fresh water peels, ponds or puddles. One of the most promising of these approaches introduces a fungus into the water which attacks the larvae, consumes it from within and then uses its body as a launching pad for producing more of itself. This method’s advantages include a relatively long persistence in bodies of water, reducing the need for reapplication, and careful testing which has revealed it to be harmless to plants and other wildlife (at least in North American waters).25 Its disadvantages include a lack of testing under tropical conditions and a need for refrigeration between production and deployment in the wild.26
The funding crisis
No matter the advantages or disadvantages of any given method, currently there is little to no work being done, privately or publicly, to refine these approaches or apply them in the countries and communities where they arc needed most. Although the US leads the world in funding anti-malarial research, it still spends only $40 million (US) on the problem,27 most of which is administered by the Department of Defense and focuses on how to protect US service personnel from malaria overseas. Worldwide the picture is even worse. According to the World Health Organization, only $85 million (US) in public funds are spent yearly on malaria in the entire world. That is slightly larger than the budget of a major teaching hospital in Boston, Massachusetts, or about two cents for every reported case of the disease.28 As one adage puts it, ‘Money is not a problem in malaria research because, basically, there is no money.’
One reason funding has been cut may be that the US and other developed nations have fallen into a false sense of security when it comes to malaria. Most Americans do not remember a time when malaria stalked the US countryside in much the same way as it now stalks Africa, but there was a time when this was so. Draining swamps and other mosquito abatement efforts are mostly responsible for the move away from malaria in the US, but a lot of credit must also go to basic technology. Wider use of air conditioning in the Southern US, for example, probably took a greater percentage of Americans out of the mosquitoes’ reach than all other mosquito abatement programs combined, but America’s poorest people’s still often open summer windows leave themselves vulnerable to potentially deadly bites. According to the United States Centers for Disease Control, mosquito borne malaria broke out in California 13 times between 1980 and 1990, twice in New Jersey in 1991, one in New York City and three times in Houston, Texas, in 1994.29 Falciparium, particularly as it becomes ever more resistant to current drugs, could make a come-back in the US.
Foreign policy implications
But a greater practical cost of America’s fixation on contraception over malarial control may yet lay ahead. Already many Africans, particularly those more educated and politically aware, note the wide discrepancy in US foreign policy between so-called “reproductive health” and any other kind. Shell reports speaking with noted African opinion makers who told her that many Africans “assume that the West considers malaria a necessary evil.” “Malaria keeps Africa down,” one told her, “and that is where the world wants us to be.” Other scientists, Westerners, were even more frank, declaring that “population control, not disease control, is USAID’s central mission in Africa.”30 But Africans will not remain down forever, and the shrinking global marketplace of both goods and ideas will not cut the US any slack. How will American businesses, trade missions and market seekers be able to do business on a continent where majorities of the rising elite hate the United States? Where, in short, will the US be when Africans come into their own?
1 The World Health Organization’s (WHO) most recent estimates place the figure for malarial deaths worldwide at between 1.5 and 2.7 million. But the Organization freely admits difficult conditions, primitive communications and lack of reliable equipment make that figure a low estimate. Further, it does not represent the numbers of people for whose deaths malaria was a primary — though not causative — agent.
2 “Malaria: avoidable catastrophe?” Nature, 10 April 1997.
3 Ellen Shell, “Resurgence of a deadly disease,” The Atlantic Monthly, August 1997.
6 World Health Organization “Disease sheet: Malaria (the current situation),” www.who.org/programmes/ctd/diseases/mala/malasit.htm.
12 Larkin, “Congenital malaria in hyperendemic area,” American Journal of Tropical Medicine and Hygiene, November 1991.
13 WHO “Disease sheet: Malaria (the current situation)”.
14 Mapping Malaria Risk in Africa (MARA) project, “Introduction,” www.mara.org.za.
16 Ettling and Himonga, “Impact of Malaria on Zambian Children,” Zambian Health Information Digest, April-June 1995.
19 Brinkman. “Malaria and health in Africa: the present situation and epidemiological trends,” Tropical Medicine and Parasitology, November 1991.
22 Committee on Malarial Vaccines, Vaccines against malaria: hope in a gathering storm,, National Academy of Sciences, 1996.
23 Curtis, “Control of Malaria Vectors in Africa and Asia,” University of Minnesota.
25 AgraQuest, “Agraquest’s Mosquito Larvae Killer,” at www.mother.com/~mjrogers/AZMosqxx.html.
26 Private correspondence with Agraquest officers.
29 Zucker, “Changing Patterns of Autochthonous Malaria Transmission in the United States,” Emerging Infectious Diseases, Centers for Disease Control, January-March, 1996.