In recent years, malaria has emerged as a cause célèbre for voguish philanthropists. Bill Gates, Bono, and Laura Bush are only a few of the personalities who have opened their pocketbooks in hopes of eradicating the scourge. How does a parasitic disease that we've known how to prevent for more than a century still infect three hundred million people every year, killing nearly one million of them? In The Fever, the journalist Sonia Shah sets out to answer this question, delivering a timely, inquisitive chronicle of the illness and its influence on human lives. The Fever captures the curiously fascinating, devastating history of this long-standing thorn in the side of humanity.
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About the Author
Sonia Shah is an investigative journalist and the critically acclaimed author of The Body Hunters: Testing New Drugs on the World's Poorest Patients and Crude: The Story of Oil. Her writing has appeared in The Washington Post, The Boston Globe, New Scientist, The Nation, and elsewhere.
Read an Excerpt
The view through the mosquito net is blurry, but I can see the
thick skin of grime on the leading edge of each blade of the
ceiling fan as it slowly whirs around, keening alarmingly.
This is how it was every summer when I visited my grandmother’s
house in southern India. While my cousins snore on the bed mats
laid across the floor beside me, glistening bodies bathed in the warm
night breeze, my sleeping mat is ensconced in a hot, gauzy cage. The
mosquitoes descend from the darkened corners of the whitewashed
room and perch menacingly on the taut netting, ready to exploit any
fl icker of movement from their prey within. It is hard to fall asleep
knowing they are there, watching me, but eventually I drop off and
my tensed body uncurls. They sneak into the gaps my protruding
limbs create, and feast.
In the morning, all my hard work of trying to fi t in, to overcome
the Americanness of my suburban New England life, has been
undone, for my Indian cousins are smooth and brown while I am
speckled with bleeding scabs. My grandmother vigorously pats talcum
powder over my wounds, the white powder caking pink with
congealed blood, as my cousins snicker. I don’t understand how they
escape unscathed while I am tormented. But incomprehension is part
of the package of these childhood summers in India. Just outside my
grandmother’s house ragged families huddle in rubble along the road
and use the train tracks as their toilet. They wave their sticklike arms
in my face and moan woefully when we pass by on the way to temple,
caricatures of beggars. One boy’s leg has swollen to the size of a log,
and is gray and pimpled, from some disease brought on by a mosquito
bite. My grandmother tightens her grip on my hand. We give
the children nothing. I can’t understand this, either. When we get to
the white marble temple, it is full of incense and golden statues
encrusted with diamonds and rubies—to my seven-year-old mind,
the very picture of prosperity.
Part of me despises my estrangement, my incomprehension, the
fact that I must sleep under the suffocating net and take the malaria
pills while my cousins don’t. But part of me is secretly glad. The boy
with the swollen leg frightens me. The family who lives on the curb
frightens me. India frightens me. These fears, for the girl who is supposed
to be Indian but isn’t, are unspeakable.
When no one is looking, I crush the mosquitoes’ poised little
figures with my palm and smear the remains on a hidden seam in
the couch. Our Jain religion forbids violence of any kind. No eating
meat. No swatting flies. My grandmother wears a mask over her
mouth while she prays, to protect airborne microbes from inadvertent
annihilation in her inhalations, and considers walking on
blades of grass a sin. Meanwhile, there I am in the corner, cravenly
pulverizing mosquito corpses behind my back, blood literally on
Back home in New England, the mosquitoes still bite, but there
are no nets at night, no pills to take, no scary beggars on the side of
the road. We shop for forgettable plastic trinkets at the mall. My fear
and loathing of the mosquito are blunted into games of tag. My father
calls himself Giant Mosquito, undulates his fingers like proboscises
and chases me and my sister. It’s scary, but fun-scary. We screech
with glee and stampede through the house.
• • •
Thirty years later, on the S-shaped land bridge between the North
and South American continents, I meet José Calzada. Calzada is a
mosquito stalker of sorts, and I, the mosquito hater, have come to
learn about the local mosquitoes and their exploits. A parasitologist
from Panama City, Panama, Calzada spends his time rushing to the
scene of disease outbreaks across the isthmus. The mosquito-borne
parasite that causes malaria, Plasmodium, is one of his specialties.
It is April 2006. For most of the past century, there hasn’t been
much work in this fi eld for people such as Calzada. Panama prides
itself on being one of just a handful of tropical developing countries
to have tamed its mosquitoes and nearly conquered malaria. American
military engineers built a canal through Panama in the early
1900s, and forced malaria to retreat to the remote fringes of the
country. Since then it has stagnated, primarily in its most benign
incarnation, vivax malaria, which is rarely fatal.
But things have changed in recent years, and Calzada has agreed
to show me some obscure signs. He emerges from the imposing
Gorgas Memorial Institute, Panama’s sole health research center.
Clean-shaven and trim, Calzada has a slightly worried look in his
eyes that is off set by high cheekbones suggesting a perpetual halfsmile.
I wait while he meticulously changes out of his work clothes—
button-down oxford shirt and slacks—and into a T-shirt and jeans.
Climbing into my diminutive white rental car and tossing a baseball
cap on top of his backpack in the backseat, he patiently directs me
out of the labyrinthine metropolis. Navigating Panama City’s congested
streets, past shiny skyscrapers and packed cafés, is a task that
challenges even my well-honed Boston driv ing skills.
After twenty minutes heading east out of the city, the road turns
quiet. It’s a lovely drive, with hills in the distance, verdant pasture
and scrub unbroken save for a few elaborately gated houses set far
back from the road. Colombian drug lords, Calzada says, by way of
explanation. Another hour passes, and the road rises, a glittering
lake coming into view, just visible through a tangle of jungle. As we
near the water, the pavement ends, and we pull over.
Here, at the end of the road, is the town of Chepo. From what I
can see, it consists of a wooden lean-to facing a sleepy roadside café.
Two police officers amble out of the lean-to, which turns out to be a
checkpoint. They take my passport and vanish, leaving Calzada and
me to buy a cold drink at the near-empty café. As we sit, I can just
make them out in the murk within the lean-to, inspecting the blue
passport with great care, turning it over and over in their hands as if
for clues to some baffling mystery.
Inspection completed, Calzada leads us on foot behind the road.
Th e hillside is green and lush, with a slick red clay track leading to
the crest. He heads up and I follow gingerly.
At the top of the hill lies an improb able settlement. Packed
together, not ten feet apart, are dozens of hand-built ranchos, their
thatched roofs sitting on top of roughly hewn wooden poles. More
arbor than hut, some of the structures rest on concrete slabs, with
airy wooden-slat walls on three sides, but most are fully open-air,
situated directly on the packed dirt. Inside the ranchos, smoldering
fi res are encircled by battered metal cooking vats, parrots sit on overturned
baskets, and hammocks sway from high rafters.
From the road, Chepo seems abandoned, but in fact, three hundred
of Panama’s indigenous Kuna people live here, tucked away.
It starts to rain, and we duck under the eaves of a rancho. Women
pass to and fro in bright puff ed-sleeve cotton blouses with patterned
molas tied around their waists and elaborate beaded anklets that
reach up to their calves. They are cutting plantains, carrying plump
naked children. One puts out a giant metal vat to collect the rainwater
sliding off the thatch. A rooster strides by purposefully.
A half-dozen boys clad in saggy cotton underwear and wearing
shell necklaces happily kick a defl ated green soccer ball. One boy,
around eight years old and wearing cracked red plastic flip-flops,
gnaws on a green mango pit while absentmindedly pulling on his
penis. A little girl walks by holding a baby covered in a rash, whom
she hands to me easily. It is a tranquil scene, earthy and ripe, this
hidden place at the end of the road.
It is soon apparent that most of the residents are in one of the
larger ranchos, sitting around a smoky fire. Peeking in, we see them
singing softly and dancing. A few are sprawled on the clay floor,
facedown, passed out. We’ve arrived in the midst of a fiesta, Calzada
whispers to me. A local girl has recently menstruated for the fi rst
time, and so the community has spent the day drinking chicha fuerte,
a brew made from fermented corn. As we watch, a woman and a
boy lift a comatose mud-caked man off the ground and drag him
home. Two women from inside the rancho follow them to the doorway,
smiling. Aside from a few furtive looks, they ignore us almost
It wasn’t like this the year before, when Calzada first came here.
There is no En glish-language record of what happened to Chepo’s
Kuna community in 2005, save the one you are reading now. The
mosquitoes that hatched from Chepo’s stagnant puddles, the edges
of the lake below, in the open-water cisterns, had gone on a rampage.
Contaminated with the most malevolent malaria parasites known to
humankind in their spittle, they alit on the exposed and unclad Kuna
around them. By the time Calzada and his team arrived, nearly half
of the settlement was fevered, terrified, immobilized in their hammocks.
After days of triage, Calzada brought samples of the Kuna’s infected
blood back to his lab at the Gorgas Institute to analyze. The
most common malaria in this part of Panama is the relatively benign
vivax strain, caused by malarial parasites called Plasmodium vivax.
Instead, Calzada identifi ed parasites called Plasmodium falciparum,
which are more commonly found in sub-Saharan Africa. Worse, this
was no regular strain of P. falciparum, but a particularly nasty one
that had evolved re sis tance to standard antimalarial drugs, a trick the
parasites may have picked up somewhere in Southeast Asia. Malaria
experts around the world had been tracking the spread of this
bug for years. At Chepo, Calzada had discovered its northernmost
There was precious little evidence, when we first arrived in Chepo,
of the village’s connection to modern industrial life. In one rancho, I
saw a battery-powered radio, but other than that, we might have
been in the preindustrial world: there were no toilets, no running
water, no electricity. But then, as the rain steadily turned the dirt
lanes between the ranchos into mud, impromptu streams formed,
ferrying Chepo’s hidden debris to the lake: a blue plastic sandal, a
crushed orange juice container, a small gas can, and a shopping bag
came bobbing down the hill. We were, after all, less than two hours’
drive from a boisterous city of three million, a center of international
commerce through which passes 5 percent of the world’s trade. The
scene of malaria’s malevolent homecoming in this secluded settlement
cast its shadow over the very doorstep of the global economy.
The 2005 epidemic at Chepo did not occur in a vacuum. On the
contrary, between 1998 and 2004, malaria cases in Panama quadrupled.
2 And globally, malaria’s death toll has grown inexorably since
In 1995, Europe suff ered ninety thousand cases of malaria. Then,
in 1996, military troops in war-torn Afghanistan sparked a malaria
epidemic across Central Asia. Soon, Azerbaijan, Tajikistan, and Turkey
suff ered malaria outbreaks. By 2003, Plasmodium had preyed on
ten times more people in Central Asia than just a decade before,5 and
a tsunami of people carrying the parasite from Africa and Asia began
showing up in Europe. Today, eight times more malaria patients
arrive at clinics and hospitals across Europe than did in the 1970s,
and back then, most of the Plasmodium imported into Europe was of
the vivax strain. Now, nearly 70 percent is the deadly P. falciparum.
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 sheer 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 also become even more
lethal. Th at’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 fl u.
Th e 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, kill ing chemicals, and know-how to avoid it,
something about this disease still short-circuits our weaponry.
After dropping Calzada off, I headed back to my rental cottage along
the banks of the canal, where I spent the evening reviewing my notes.
Th e cottage was on stilts, and cooled by ceiling fans, but the window
screens were old and sagging, bent and giving way from the window
frame. Every morning in Panama I would awaken with some
unexpected swelling from the mosquitoes’ nighttime blood feasts:
under my eye, on my eyelid, on the palm of my hand. Smashed mosquitoes,
glued to the surface with their own internal juices, dotted
A flimsy mosquito landed gently on my forearm. A familiar spike
of rage rose as I watched, incredulous, as the insect prepared to puncture
my skin with her proboscis. How dare she! Instinctively, my hand
Somewhere inside that cold-blooded, brittle body lurked entities
whose exertions explained the making of rich and poor, sick and
healthful. My hand came down a bit slower for the passing thought,
and I brushed the mosquito away like a crumb. Her delicate legs
snarled together, pitching the insect’s body forward at a steep angle.
Mangled, she skittered off my arm awkwardly as I watched, my vestigial
Jain sensibilities slightly horrifi ed. Finally she reached the precipice,
where she somehow took flight and vanished.
Table of Contents
Contents1 MALARIA AT OUR DOORSTEP,
2 BIRTH OF A KILLER,
3 SWEPT IN MALARIA'S CURRENT,
4 MALARIAL ECOLOGIES,
5 PHARMACOLOGICAL FAILURE,
6 THE KARMA OF MALARIA,
7 SCIENTIFIC SOLUTIONS,
8 THE DISAPPEARED: HOW MALARIA VANISHED FROM THE WEST,
9 THE SPRAY-GUN WAR,
10 THE SECRET IN THE MOSQUITO,