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The New York Times
January 8, 1997
Malaria Makes a Comeback, Deadlier Than Ever
By NICHOLAS D. KRISTOF
MWANABWITO, Tanzania -- Her face was calm and soothing, but Mariam Karega's eyes brimmed with fear as she cradled little Hussein and nursed him, trying to pump life into him along with her milk. "I'm losing hope," Mrs. Karega said, her big aching eyes radiating the terror of any parent holding a dying child. "He's tiny and he's stopped growing. And although he'd started to walk, now he can't anymore. I don't think he'll make it." It was a sweltering afternoon, and a dozen other villagers sat solemnly around Mrs. Karega and her 15-month-old son, a knowing sympathy hanging in the air along with the flies.
In this village of thatched mud huts in rural Tanzania, in East Africa, the trauma of losing a child is almost as common as a scraped knee. These children are dying not from something intuitively monstrous, like the crocodiles that lurk in the Ruvu River below the village, ready to spring on any unwary bather. Instead, the children are dying of mosquito bites.
In 1996, alone, between 1 million and 3 million people died of malaria, the mosquito-borne disease that has struck Hussein and the other children in the village. Most alarming, malaria, far from coming under control, is becoming resistant to medications and is expanding into new areas and killing many more people than it did a few decades ago.
For these reasons, the World Health Organization recently declared that "public health enemy No.1" is the mosquito. Americans may think of medical care as incalculably complex, a world of angioplasty and echocardiograms and other technologies that to many people are as incomprehensible as they are unpronounceable.
But for most people in the world, the challenges of health care are simpler: when mothers like Mrs. Karega hold dying children, it is usually because of something as simple as dirty water or a mosquito bite. While medical care has made tremendous strides in recent decades, some of the most formidable challenges remain the most basic: providing people with toilets and clean water, and protecting them from deadly mosquitoes. The extraordinary thing about the mosquitoes is that in the current battle against the best minds of 20th-century science and medicine they may be winning.
In the 1950s, experts were optimistic that malaria could be wiped out, and for a time DDT and other insecticides led to a sharp reduction of mosquitoes and of the disease. But the use of DDT and similar chemicals was sharply curtailed because of their dreadful environmental effects, and, partly as a result, malaria began a long upswing around the world in the 1960s and '70s.
"As a single disease, malaria has a bigger impact on the world than anything you can think of," said Dr. Kazem Behbehani, director of the division for control of tropical diseases at the World Health Organization in Geneva. "And it's spreading."
Between 300 million and 500 million people now get malaria each year, and someone dies of it about every 15 seconds -- mostly children and pregnant women. Over the last decade, malaria has killed about 10 times as many children as all wars combined have in that period. The cumulative statistics have so many zero's that it is impossible to conceive of the heartbreak that they represent.
People in developed countries sometimes suppose that Third World villagers are so familiar with suffering that they are numbed to it, but anyone who thinks that should have seen Mrs. Karega's eyes -- or should have been hiking on a muddy path in the Cambodian jungle, 7,500 miles to the east.
Banana trees dotted a starkly beautiful hillside of brilliant greens, but from up ahead an eerie wailing resonated through the trees, a shrieking that at first sounded inhuman. It turned out to be human after all, coming from a wretched farmer named Yok Yorn, 48, a man with a gray crew cut, a long face, square chin, and tear-stained cheeks. He was bent over the body of his 7-year-old son, Kaiset, who had died of malaria a couple of hours earlier.
The boy's body lay on the floor, half-covered by a blanket, as his family sobbed around him and other villagers tried to comfort them. Yok Yorn was the most distraught: as tears trickled down onto his son's body, he cradled the boy's head and put his own next to it, rubbing his hair against his son's.
The boy had become seriously ill with malaria a week earlier, and Yok Yorn had carried him piggyback down the path to a local doctor. Yok Yorn borrowed the $50 doctor's fee and did not think twice about handing over what in local terms was a colossal amount, equivalent to tens of thousands of dollars for an American family.
"This was the smartest boy in the family," Yok Yorn said softly when he had recovered his composure enough to speak. He added that his grief was compounded because Kaiset was his second son to die of malaria. His eldest child, Thad, 16, also died of the disease. Yok Yorn looked around at his other five children. His voice broke as he whispered: "I'm so afraid that my other children will die of malaria as well."
Safeguards: A $5 Net Can Help, but Cash is Lacking. Doctors say that there is no reason why children like Kaiset have to die, and that they can usually be saved if they get prompt treatment from a good doctor. But that is often impossible in the Third World, where well-trained doctors are scarce. Cambodia has only one doctor for every 9,500 people compared with one for every 387 in the United States.
Drugs are normally used to treat malaria, although drug-resistant strains are becoming a problem all over the world and especially in Southeast Asia. In addition, mosquitoes are emerging that are resistant to ordinary insecticides, and, together, they make a ferocious combination: super mosquitoes armed with drug-resistant super malaria.
But the situation is far from hopeless. A new drug called Malarone has done very well against malaria in clinical trials, both as a treatment and as a preventive, according to data made public at a recent international conference. Malarone will undergo further testing, and experts also cite a slew of technical reasons to argue that with time and money a successful vaccine can probably be developed.
Until an effective vaccine is developed, experts say, the best approach is simply to keep mosquitoes from biting people. The anopheles mosquito, the variety that carries malaria, tends to bite after dark, and so several recent studies have suggested that sleeping inside a mosquito net impregnated with insecticide can reduce malaria sharply.
For now, however, the impregnated nets are not widely available in street markets of developing countries, and the insecticide has to be reapplied at least once every year. A more fundamental problem is that many people cannot afford even ordinary mosquito nets, which cost $5 or $10.
"We have no blanket, no medicine, and not enough food to eat," said Soy Phal, 31, a Cambodian who is herself feverish with malaria and whose husband died of the disease three years ago. "How can I afford a mosquito net? I spend my life being sick, so I have no time to earn money to get a mosquito net."
Mrs. Soy Phal's complaint is echoed by development economists. They note that malaria and other tropical maladies create a cycle in which disease hinders economic development and thereby sustains the disease.
Take Jamaluddin, a 36-year-old man with a black beard and deep-set eyes who lives in Bhadas village, in northern India. Until a few months ago, he ran a tea shop and earned enough so that he was gradually climbing out of poverty. Then he and his entire family suddenly caught malaria, and, within two weeks, in October, he had lost one of his two wives and three of his seven children. Medical and funeral costs left him $350 in debt, so that he was forced to give up the lease on his tea shop as well. <
"I don't know if my life will ever get back on track," said Jamaluddin, who now hopes to get odd jobs as a laborer, paying $1.40 a day. "I'm completely shattered." The last thing Jamaluddin can afford is a mosquito net to save his remaining children. But Nhem Yen is perhaps even worse off. Mrs. Nhem Yen, a Cambodian villager, has one small mosquito net -- and that is the source of her anguish.
A 40-year-old woman, Mrs. Nhem Yen has five children and two grandchildren in her little hut. Every evening, she must figure out which children sleep under the net, and which sleep outside the net and risk death. "It's very hard to choose," Mrs. Nhem Yen said softly, her children clustered around her. "But we have no money to buy another mosquito net. We have no choice."
Mrs. Nhem Yen is looking after two granddaughters because their mother died of malaria recently at the age of 24, just a day after giving birth. The dead woman, Mrs. Nhem Yen's daughter, never saw a doctor -- it would have cost too much. The elder granddaughter, a puffy-cheeked 3-year-old with a dimple on her chin, does not yet understand that her mother is dead. The younger one, just two weeks old and frail, surviving on cow's milk, still lacks a name because she seems unlikely to linger. For now, Mrs. Nhem Yen gives these two the place under the mosquito net, but she knows it may be a losing gamble: the two-week-old may die anyway and in the meantime is taking up the life-saving space under the net.
Research: Little Money is Spent to Fight Malaria. One reason for optimism in the struggle against mosquito-borne diseases is simply that science has shown that it can often conquer age-old scourges when given the resources. Leprosy used to be one of the most dreaded of diseases, but it now is easily cured with drugs and may soon be virtually wiped out around the world. The same is true of polio.
But malaria remains a medical catastrophe in part because it does not get much in the way of resources. Only about $85 million a year is spent globally on malaria research, about half as much as is spent on asthma research.
A recent British study estimated that each year $3,274 is spent on AIDS research for each fatal case of AIDS, while $65 is spent on malaria research for each fatal case of malaria. Money for malaria research is meager in part because the disease primarily afflicts poor people, and Western drug companies doubt that Third World villagers would be able to pay much for a new malaria vaccine even if it was developed.
Another reason malaria is the exception, a disease that is killing more people than three decades ago, rather than fewer, is that it is difficult to imagine a more vexing adversary than the mosquito. The mosquito has been on Earth at least 40 times as long as humans, and it has proved a more wily antagonist than wolves or saber-toothed tigers. It is only the female mosquito that bites -- to get blood to nourish its eggs -- and that is when it transmits diseases. The mosquito does not itself catch malaria or yellow fever or encephalitis or the many other ailments that it can carry.
Malaria parasite cells multiply in the infected person's liver and cause severe fevers with hot and cold chills. Depending on the variety of malaria, the patient can fall into a coma, have seizures, or suffer from anemia, kidney failure, or rupture of the spleen. Survivors of the worst kind, cerebral malaria, are sometimes mentally retarded.
Experts are learning some tidbits about mosquito habits: they are finicky, often preferring animal blood to the human variety; they like dark colors; they are drawn to sweat; they respond to hormones and avoid menstruating women. But above all, what strikes many entomologists is that mosquitoes are enormously adaptable to new threats and environments. That helps them expand into new regions, bringing diseases with them.
Until 1970, only nine countries had experienced epidemics of dengue hemorrhagic fever, a mosquito-borne disease for which there is no cure or vaccine and which causes the victim to bleed from the mouth, nose, and gums. Since then, 29 more countries have experienced outbreaks, and a milder form of the disease, called dengue fever, has struck people in Texas.
Some entomologists worry that global warming may expand the habitat of the anopheles mosquito. The World Health Organization has warned that a result may be anopheles mosquitoes' living in places like the southern United States and southern Europe, and an extra 80 million cases of malaria annually by the end of the next century.
Another particularly dangerous kind of mosquito, the Asian tiger mosquito, which can carry dengue fever, encephalitis, and yellow fever, arrived in Texas in 1985, apparently in a shipment of tires from Asia, and has now established itself in several other states.
Malaria itself has cropped up recently in parts of the former Soviet Union, and it now is endemic in 91 countries. In little villages that dot the dirt roads of Rajasthan and Haryana States in northern India, melancholy farmers stand in their hushed doorways and say they had never heard of malaria locally until their loved ones began to die of it a few months ago.
"I don't remember anything like this in all my life here," rasped Jabar Khan, the white-bearded 80-year-old patriarch of Agaon village. "I lost a grandson and two granddaughters, but I still don't understand what happened. They were sick with fever, and they began shaking so much that their teeth chattered. Then they died."
Poverty: For Children's Sake, a Fearful Gamble. Parents in poor countries can face excruciating choices: often the only way to give their children an opportunity is to gamble with their lives. In Cambodia, the death toll from malaria is rising in part because families are knowingly moving to malaria zones. They move there to earn the princely sum of $2 or $3 a day, enough to feed and clothe the children and send them to school so that they can escape the cycle of poverty. The catch is that the pay is high because of the deadly risks.
"I can't stand being here, because it's no use being rich if your children die," said Chim Savan, 36, who was preparing dinner in her hut as dusk fell in a village in the malaria zone. "Right over there, in that house, there was a family living with two children, about the age of mine, a boy and a girl. But they lost both children because of malaria, and so now they decided to move away."
So why does Mrs. Chim Savan stay in the village? It is not just that her husband has a job there cutting wood and thus the family has food to eat, or even that the family's entire savings -- $4 -- were spent when they moved here in April. Rather, the problem is that the family puts honor above all else.
One of the couple's four sons, Rathna, a 5-year-old who was scampering naked around the hut, nearly died of malaria a couple of months ago. Mrs. Chim Savan managed to save his life, but only by borrowing $22 so that he could spend a week in a hospital for a blood transfusion and other treatment.
So now the parents have saved Rathna, but they feel they are honor-bound to stay in the village until they can repay the $22 to the woodlot owner, who lent them the money. The risk is that in the meantime their other children will die.
If I weren't in debt I would leave," Mrs. Chim Savan said. "But when we were in trouble, the owner helped us, so now we have to help him. Because he was good to us. "We're scared that the loan will have saved one child's life while costing us the lives of our other children. But what can we do?" In talking to women like Mrs. Chim Savan, one is reminded that it is not just diseases that kill people, but also poverty.
Malaria itself is not such a deadly threat when it strikes people who are healthy and rich. But in the Third World, few people are healthy to start with, and they lack the resources to buy mosquito nets, to drain swamps that breed mosquitoes, and even to get simple treatment to save the lives of those most important to them.
Mrs. Karega, the Tanzanian woman who fears for the life of her 15-month-old toddler, who cannot toddle, said a nurse at a rural clinic told her to take little Hussein to the district hospital, so that a doctor could look at him and examine his blood and perhaps save him. "But we can't afford to do that, "Mrs. Karega said, looking down at Hussein as he nursed from her breast. "That would be too expensive. We don't have that much money." How much would it be? Mrs. Karega answered at once, for she had worked out the sums many times in her head, searching for a way to gather the money: "Including round-trip transportation, the lab test, and a tip for the doctor, it would cost 10,000 rupees. We just can't afford that." The amount is equivalent to $16.65.