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At the outset of the twentieth century, malaria was Italy's major public health problem. It was the cause of low productivity, poverty, and economic backwardness, while it also stunted literacy, limited political participation, and undermined the army. In this book Frank Snowden recounts how Italy became the world center for the development of malariology as a medical discipline and launched the first national campaign to eradicate the disease. Snowden traces the early advances, the setbacks of world wars and Fascist dictatorship, and the final victory against malaria after World War II. He shows how the medical and teaching professions helped educate people in their own self-defense and in the process expanded trade unionism, women's consciousness, and civil liberties. He also discusses the antimalarial effort under Mussolini's regime and reveals the shocking details of the German army's intentional release of malaria among Italian civilians the first and only known example of bioterror in twentieth-century Europe. Comprehensive and enlightening, this history offers important lessons for today's global malaria emergency.
And truly the malaria gets into you with the bread you eat, or if you open your mouth to speak as you walk, suffocating in the dust and sun of the roads, and you feel your knees give way beneath you, or you sink discouraged on the saddle as your mule ambles along, with its head down. In vain the villages of Lentini and Francoforte and Paternò try to clamber up like strayed sheep onto the first hills that rise from the plain, and surround themselves with orange groves, and vineyards, and evergreen gardens and orchards; the malaria seizes the inhabitants in the depopulated streets, and nails them in front of the doors of their houses whose plaster is all falling with the sun, and there they tremble with fever under their brown cloaks, with all the bed-blankets over their shoulders. -Giovanni Verga, "Malaria"
The full extent of the prevalence of malaria first captured national attention in the decade following 1878. It had been known for centuries, however, that intermittent fever was prevalent in the Italian peninsula. The very term malaria (bad air) was Italian, and Italy possessed "the unenviable privilege of having given this word to the world." Before 1861, when "Italy" referred to a peninsula instead of a nation-state, it was as infamous for its lethal fevers as it was famous for its beauty. The radical revolutionary Jessie White Mario reported that midcentury Sardinia had such an evil reputation for malarial fever that "none but those utterly destitute or compelled by the pressure of insurmountable circumstances would think of remaining there."
Camille de Cavour, the first prime minister of the new kingdom of Italy, died tragically of malaria in 1861 just after unification was completed. The Pontine Marshes and the Roman Campagna had been notorious for their insalubrity since ancient times, and for centuries travelers dreaded crossing them during the summer fever season. Henry James and Emile Zola remind us that fever lurked in Rome as well, where hotels in the healthier quarters found it profitable to inform potential customers that their neighborhoods were risk-free. One of the alternative names for the disease, "Roman fever," clearly suggested the danger, and those residents who were sufficiently wealthy fled the city in the summer to avoid the fate of James's Daisy Miller, who perished of fever in the Italian capital. Most famously of all, Giuseppe Garibaldi-the hero of the doomed Roman Republic of 1849 and one of the nation's founding fathers-lost both his wife, Anita, and large numbers of his troops as they retreated across the Roman Campagna during a fearsome epidemic of malaria. The Italian army suffered a similar fate in 1870 after capturing Rome from the Pope, and soldiers filled the wards of the city's fever hospital. Thus stricken, Garibaldi urged the newly united nation to place the fight against malaria high on its list of priorities.
Clearly, then, the fact that malaria existed in the kingdom of Italy surprised no one. Awareness of the disease, however, was partial, imprecise, and anecdotal. For a quarter of a century after unification in 1861, malaria was not reportable, and the official attempt to document and quantify its ravages did not begin until 1887. Furthermore, the rural poor, who suffered disproportionately from malaria, had little or no contact with the medical profession. As a result, their condition was only vaguely apprehended before 1887, and even after the age of health statistics began, the incidence of the disease remained seriously underreported. Greatly limiting public knowledge of the disaster were various additional circumstances: distance, poor communications, the barrier of mutual ignorance dividing North and South, absenteeism, the abyss between city and countryside, and universal uncertainty about the nature of the disease itself, which remained, in the phrase of the Roman physician Francesco Puccinotti, "the darkest of mysteries." The cost of malaria to Italy had never been calculated. Antonio Labranca, inspector general of the Department of Health, recalled in 1928 the imprecise perception of malaria prevailing at the time of national unification: "Only with the establishment of the kingdom of Italy did the problem of the war against malaria begin to be apprehended in its full enormity, but there was still no precise knowledge of its diffusion and severity. In particular, with regard to the prevalence of malaria in the territory of the kingdom, its influence on the physical and sanitary condition of the nation, and its impact on the national economy, there were only vague notions. One was still far from being able to assess all the effects of swamp fever and malaria."
Then, in 1878, an alarm was sounded by an unlikely source: a report from the Parliamentary Railway Commission. One of its leading members, the Tuscan senator Luigi Torelli, the earliest apostle of a nationwide antimalarial program, discovered during his work for the commission that malaria was inseparable from any investigation of the railroad industry because of the appalling rate at which its employees fell ill in vast swathes of the country. For instance, in 1878, 1,455 of the 2,200 railroad workers in Sicily required medical attention for malaria. Torelli proclaimed the emergency in parliament, calling for a systematic investigation of the prevalence of the disease and an assessment of its cost. He sponsored a bill for a national land-reclamation program to combat malaria, and he undertook drainage works on his own estates. In order to substantiate his claims, Torelli also solicited reports on fever from all 259 of the provincial and district health councils (consigli di sanità), thereby confirming the urgency of the crisis.
Unwilling to allow so vital an issue to slumber in the halls of parliament at Montecitorio, Torelli launched a campaign to arouse public opinion. In 1882, he began by drafting the first map of malarial Italy. The purpose of this map was to shock the public by dramatically revealing-in yellow and red patches of "severe" and "very severe" prevalence-the full extent of the fever that made Italy a "sick beauty." Then Torelli published Il curato di campagna e la malaria dell'Italia (The Country Priest and Italy's Malaria) in 1884. Il curato di campagna was an educational document organized in the form of fifteen short dialogues on fever and intended to reach a broad readership. As Torelli patiently explained in the dialogues, malaria was so widespread and so devastating that it ranked chief among the problems facing the Italian nation. He therefore called for an all-out "national war" to liberate Italy from the "tyranny of malaria," and he predicted that the war would pay for itself through reduced health costs and the improved productivity of the Italian workforce.
Torelli's findings were rapidly confirmed by two further fact-finding investigations. The first was the famous parliamentary inquiry into the conditions of Italian agriculture conducted under Stefano Jacini and published between 1881 and 1886. Jacini and his colleagues discovered that, in the dawning era of global competition inaugurated by steamships and railroads, Italian farming was dangerously backward and highly vulnerable to efficient American and Russian competitors. One of the leading reasons for this weakness, the inquiry discovered, was the ubiquity of fever, which fatally compromised the health and the productivity of peasants and farmworkers. Jacini himself largely avoided the issue of disease in his final report, but several of the commissioners for specific regions carefully documented its influence. Senator Francesco Nobili-Vitelleschi, for example, reporting on the provinces of Rome and Grosseto, concluded that malaria was a "terrible scourge that covers immense areas of Italian soil with a funeral pall. There it is our great misfortune that only the scythe of death reaps an abundant harvest." Similarly, Baron Giuseppe Andrea Angeloni reported from Apulia and the Abruzzi that, as a result of malaria, "the traveler who crosses our countryside is pained by the squalor in which he finds it." Both Angeloni and Nobili-Vitelleschi explicitly applauded the results of Torelli's labors, endorsed his map, and supported his conclusions. Francesco Salaris, the commissioner for Sardinia, complained that the ravages of malaria were sometimes exaggerated, but he noted of his native island that "in the villages located in these extensive plains, and along the coasts, the poison of malaria lies always insidiously in waiting. In the faces of our men, women, and children one can see the grayish pallor of repeated attacks of fever. It is well known that the dominant disease in many parts of the island is swamp fever, and that neglect and complications can make it serious or even fatal."
In 1887 the Italian state launched a second investigation by beginning to collect and publish health statistics. Declaring malaria a reportable disease, the Department of Health (Direzione Generale della Sanità) produced a statistical profile that illustrated the urgency of taking action.
What did investigators discover about malaria that gave them such a sense of crisis? What was the extent of the Italian malaria problem in the closing quarter of the nineteenth century? Where in the kingdom was it most intense? What was the profile of its victims? What was its seasonality? How did contemporaries understand the disease? This chapter surveys what soon came to be called the "Italian national disease" on the very eve of the great discoveries that unraveled its mysteries and just before the campaign to eradicate it was launched. The intention, however, is to avoid the anachronism of using modern scientific understandings of malaria to explain-or explain away-the great challenge that faced nineteenth-century Italians. It is important instead to sense the alarm that contemporaries felt as the full measure of the problem captured national attention. To that end, it is essential to begin by examining the problem as they saw it, and in their own terms.
Malaria as Miasma
In the 1870s, as Luigi Torelli began to address the crisis, Italians-both scientists and nonscientists-almost universally understood malaria in terms of "miasmatism." According to this interpretation, fever was caused by a "miasma," or poisoning of the air. Francesco Ladelci, a prominent Roman physician and authority on fever, defined miasma as "a disease-causing emanation that rises from wet earth, especially where there is stagnant water and the earth dries out during the heat of the summer." Indeed, here was the etymological origin of the disease's name-"bad air," or mal'aria. Opinions diverged over the nature and source of the noxious effluvium. For many, the poison was a chemical that arose from organic material that had fallen into swamp water and then decomposed, releasing pestilential vapors into the atmosphere. In this view, malaria, often called paludismo (swamp fever), erupted when susceptible individuals inhaled the gases or absorbed them through their pores. A crucial factor, therefore, in the epidemiology of each locality was the direction of its prevailing winds. In the case of Rome, fever broke out in the late spring and summer when southern trade winds prevailed and wafted deadly swamp gas from Africa, from the nearby Pontine Marshes, or from the swamps at the mouth of the Tiber at Ostia. When autumn returned, cold winds gusted safely again from the north, and the city returned to health.
In the opinion of many, however, it was not necessary for individuals to poison themselves directly from swamp gas in order for epidemic malaria to burst out. A widespread theory was that the lethal swamp material was not a chemical but a living entity, or "germ," that was variously regarded as a microscopic plant or an invisible "animalcule." In this interpretation, winds bore the germs away from the swamps and, even at great distances, seeded the ground as they passed over it. Under the proper conditions of warm temperature, intense humidity, and an impermeable clay topsoil that retained moisture, the germs would ferment in the earth, releasing poisonous fumes. This was the telluric doctrine of malaria, which postulated that not the air but the earth was poisoned. As Corrado Tommasi-Crudeli stated, "Malaria is a production of the earth." Under the influence of the work of Louis Pasteur, Joseph Lister, and Robert Koch, who established the modern "germ theory of disease," some malariologists-most notably Tommasi-Crudeli, Edwin Klebs, and Ettore Marchiafava-even claimed to have isolated the microbe, or Bacillus malariae, that infected the soil. The concept of a living organism that could reproduce infinitely seemed the most rational explanation for the sheer magnitude of the malaria problem.
According to this theory, people became infected when they crossed the contaminated "fields of death" and breathed in the poisonous vapors, or when they ingested the germs directly by drinking contaminated swamp water. Men and women were thought to be particularly vulnerable if they found themselves in the open fields at times when sharp changes in atmospheric temperature occurred, causing currents of air to rise vertically from the earth and bear the miasma aloft. For this reason, dawn and dusk-times when swift changes in temperature regularly took place-were exceedingly dangerous. Similarly, there was thought to be great danger in such activities as plowing or excavating, which involved moving the earth and therefore liberating the ferment. In addition, any malodorous task was a cause for disquiet. The retting of hemp and linen, for example, which produced a terrible stench, fell under deep suspicion.
The sway of such miasmatic teaching was powerfully reinforced by the German epidemiologist and sanitarian Max von Pettenkofer, who enjoyed a great vogue in Italy in the closing decades of the nineteenth century even as his authority waned in his native country. Although Pettenkofer concerned himself primarily with Asiatic cholera, the careful attention he devoted to the role of local environmental factors-especially groundwater, temperature, and air-in the etiology of disease was applicable to the study of malaria as well. As with cholera, the implication was that malaria was not a contagious disease. Indeed, malaria was deemed to be the miasmatic disease par excellence because the pathogenic material, having once gained entrance into the body, was not excreted and was therefore not capable of being transmitted from person to person. Malaria was purely a product of local factors of climate and topography. The epidemiology of the disease thus became, in the words of the Roman doctor Francesco Scalzi, a question of "medical meteorology."
Naturally, not everyone exposed to the malarial miasma fell ill. Invoking concepts that had formed part of humoral teaching since antiquity, physicians believed that the individuals who contracted fever were predisposed as a result either of their inborn constitution ("diathesis") or of external "occasional causes" that weakened their resistance. These occasional causes included emotional distress, preexisting infections, dietary excesses and irregularities, severe overwork, and sudden chills that blocked the purifying action of perspiration and allowed the poison to accumulate in the body. In such susceptible individuals, nineteenth-century doctors thought, the miasma produced its effects by attacking the central nervous system. It was this ability to affect the solar plexus, the ganglionic nerves, and the spine that explained the protean variety of malarial symptoms. After a latent period of seven to ten days following exposure, the poison triggered the onset of symptoms. Thereafter, the classic paroxysms of malarial fever occurred-intermittent spikes of temperature, chills, profuse sweating, and violent headaches. Vomiting, diarrhea, and delirium were also common. The subsequent course of the disease was then determined by the specific organs and systems that were affected by the poisoned nerves-the brain, the lungs, the spleen, the gastrointestinal tract, or the circulatory system. In the worse cases of "pernicious" malaria involving vital organs, death resulted swiftly as the patient collapsed into coma, acute respiratory distress, or profound anemia. Pregnant women were subject to miscarriages, premature births, and massive hemorrhage.
Excerpted from The Conquest of Malaria by FRANK M. SNOWDEN Copyright © 2006 by Frank M. Snowden. Excerpted by permission.
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|1||Malaria : the "Italian national disease"||7|
|2||From Miasma to mosquito : the Rome school of malariology||27|
|3||A nation mobilizes||53|
|4||From quinine to women's rights : hopes, illusions, and victories||87|
|5||The First World War and epidemic disease||115|
|6||Fascism, racism, and Littoria||142|
|7||Creating disaster : Nazism and bioterror in the Pontine marshes||181|
|8||Fighting disaster : DDT and old weapons||198|