The Fever Read online

  Mortality rates in the infected counties rivaled those of present-day sub-Saharan Africa.2 Other microbes swooped down in periodic epidemics that could carry off as much as 20 percent of the population. Despite the region’s rich agricultural soil and its proximity to the coast and the commerce of London, fewer people lived in the marsh counties than anywhere else in England.3 And those who remained were perhaps not England’s finest. Vicars fled the afflicted marsh parishes, and the resulting lack of religious instruction, coupled with the local habit of treating malaria with liberal volumes of alcohol and opium, probably had something to do with it.4

  The marsh counties’ malaria also posed a danger to the packed masses in London, just upstream on the Thames. Sulphurous salt marshes stretched right across from the Palace of Westminster, and now and again, during an especially warm or wet season, infected Anopheles from the marsh counties would colonize the crowded city.5 Sir Walter Raleigh, captive in the Tower of London on the Thames in 1592, “prayed fervently to God that he might not be seized with an ague-fit on the scaffold, lest his enemies should proclaim that he had met his death, shivering with fear.”6 In 1661, malaria outbreaks so roiled London that Parliament House declared a day of fasting to “pray for more seasonable weather.”7

  • • •

  By the nineteenth century, Britain had more effective ways to counter malaria than divine entreaty. By then they knew the disease was linked to stagnant waters and could be alleviated with improved drainage. But even at the height of its powers, the British Empire did little to disrupt malaria. Political will to tackle the scourge coalesced only to protect a select few.

  In Britain’s West African colonies, British colonists were the chosen. Although British scientists and officers posted in African colonies pressed London’s Colonial Office for supplies to improve drainage, which they felt certain would alleviate the ubiquitous malaria, Colonial Secretary Joseph Chamberlain decreed that rather than beat back malaria for the public’s benefit, the British policy would be to sequester the Europeans as far away as possible from the mosquito-ridden lowlands and the malarious native subjects who lived there. Chamberlain sent confidential letters to the governors of the colonies with instructions that all new buildings be located “away from native quarters.” “On no pretext whatever should residences be built near any native quarter, or that native quarters be allowed to spring up in the midst of the new European quarter,” his advisors warned. “Otherwise the inevitable result will be that malarial fever, contracted from the native children, will be as rife, if not more so, as it is in Lagos.”8

  And so, above Freetown, the Crown built a segregated European-only enclave with one hundred tons of English cement and prefabricated bungalows. Called Hill Station, it boasted brand-new houses, a rail line, playing fields, exclusive clubs, and fresh, clean water running through pipes. The authorities banned Africans from settling anywhere within a mile radius of the new town, or from even entering any of the gated compounds. All of the clubs and fields were surrounded by a 440-yard-wide band in which no native people (except the “bona fide servants of Europeans”) were allowed. The benefits of this selective defense against malaria rippled through the culture. Hill Station residents avoided not just malaria but the indignity of living near “dirty, overcrowded” native huts. They enjoyed quiet nights, free of the buzz of the mosquito as well as the “drumming and other noises dear to the Native.”9

  During World War I, British soldiers were the chosen few. Like sleepwalkers snapping to wakefulness, some of the same medical officials who expressed apathy about taming malaria in Africa threw themselves into robust and effective antimalaria campaigns to protect the troops. They conducted surveys; they mapped malaria’s geography. In all the places where British troops congregated, “innumerable ponds were filled in or drained,” writes the medical historian Mark Harrison. “Where this was not possible, petroleum spraying of breeding pools was carried out.” With the improved methods made possible by the discoveries of Ross and Grassi, they introduced fish to devour mosquito larvae, distributed mosquito nets, and dredged silt from river-beds to wash away larvae.10

  In contrast, in British-ruled India, the British knowingly worsened malaria. There, they built dams across scores of wild Indian riverways, creating thousands of miles of irrigation canals.11 The irrigated farmlands were better for wheat, sugarcane, cotton, indigo, and opium—export crops the British authorities could tax—than for the locals’ traditional sustenance crops. And the East India Company could charge locals five rupees for every acre of farmland watered by the new canals. Plus, as one commentator put it, the transformed Indian agriculture would better “preserve the people from starvation.”12

  But locals complained that bouts of malaria followed in the wake of the new canals. They knew the drawbacks to their traditional irrigation schemes, such as inundation canals, which were labor-intensive and only seasonally useful.13 About a quarter of the harvest was lost every year due to variable rainfall, and rural Indians lived in fear of sporadic famines.14 But Indian farmers famously conserved the waters they did collect. This was holy stuff, after all: the water goddess Ganga incarnate.15 Plus, traditional methods minimized disruption to malaria ecologies. The fish that swam through the inundation canals fed on Anopheles larvae.

  An 1845 report by a British officer, T. E. Dempster, found that the new irrigation canals disrupted natural drainage patterns, with the result that when it rained, sheets of water spread across the plains, forming Anopheles-friendly bogs and swamps. “All our previous knowledge and experience would lead us to suspect some mischief from irrigating canals in such a climate as that of India,” Dempster opined, “especially, if not expressly constructed so as to preserve the drainage of the country.” And yet, the canals had been built “without any view to preserving the drainage of the country,” and so had “ every where impeded or absolutely obstructed it.” As a result, the people who lived in the newly irrigated villages suffered a tremendous malarial burden, their spleens swollen at twice the rate as those in unirrigated or traditionally irrigated villages, Dempster reported.16

  Rural, conquered Indian subjects, however, were not the chosen few. The construction of irrigation projects continued unchanged. When confronted with the extent of Indian malaria, British medical officers who’d commanded effective anti-mosquito campaigns to protect British troops, such as the Indian Medical Service’s Samuel Rickard Christophers, emanated “an impression of indecisiveness,” according to Christophers’s fellow malariologists H. E. Shortt and P.C.C. Garnham.17 British authorities refused to conduct another survey on malaria and irrigation, condemning the idea as “foolish” and a “wild scheme.” By 1894, fever took the lives of five million Indians, about a quarter of them thanks to malaria.18 In 1908, a malaria epidemic in heavily irrigated Punjab killed three hundred thousand over the course of a few months.19

  British exclusivity in malaria control did not escape the notice of outside commentators. A 1929 League of Nations commission called the British malaria policy in India “sanitary inaction.”20 The nurse Florence Nightingale called it a failure of compassion. “We do not care for the people of India,” she bemoaned. “How else to account for the facts about to be given? Do we even care enough about their daily lives of lingering deaths from causes we could remove?”21 Medical officers who lived below Hill Station complained that antimalarial segregation undermined the British imperial mission to educate and civilize the natives.22

  British authorities were unapologetic. Antimalarial segregation may not be “a just method, for the native is neglected,” a top British medical official allowed, but it was “not right to sacrifice the European lives . . . to such sentimental ideas.”23

  For the nineteenth-and early twentieth-century British, the difficulty and cost of antimalarial measures, and the fact that the neglect of socially powerless people was considered a normal part of life, justified selective use of malaria-control techniques.

  The calculus was the same
across the pond, among the populist Americans.

  As in Britain, malaria had spread across what would become the United States before anyone knew any better, as European settlers and their African slaves unknowingly contaminated the New World with P. vivax and P. falciparum parasites. After the American Revolution, malaria spread westward, rooting deep into the Mississippi Valley, an expanse of nearly continuous mosquito habitat that lay between the Appalachian and Rocky mountains.

  Malaria took 80 percent of settlers in Pike County, Illinois, in the 1820s, and eighty of six hundred Norwegian settlers in Wisconsin in 1841. It destroyed an 1830s effort to build a canal between the Great Lakes and the Mississippi River. Cruising down the Mississippi, northern passengers ogled the “sallow faced . . . pitiable looking objects” that emerged from mud huts, sod houses, and dugouts along the river’s banks. Their bloated spleens distended their bellies by nearly a foot. It was the “swamp devil,” one boat captain explained. “I’m feared you will see plenty of it if you stay long in these parts,” he said to a passenger.24 “Don’t go to Michigan, that land of ills,” a mid-1800s song advised, “the word means ague, fever and chills.”25

  The disease barrier malaria created was so fierce that many felt the West would never be settled. Nevertheless, it wasn’t the sallow-cheeked denizens of the Mississippi Valley who were the beneficiaries of the first purposeful U.S. campaign against malaria, which began in 1903.

  The fight was waged much farther south, on the isthmus of Panama, where the United States hoped to build the canal that had eluded the French, the Scots, and the Spanish before them. To do it, they’d need to secure a healthful population of workers in one of the most malaria-infested parts of the continent. Here, too, the antimalarial techniques they enacted—in pursuit of economic goals—were restricted to a chosen few.

  The man chosen to lead the attack on Panama’s disease was a military doctor named William Crawford Gorgas. He’d never been particularly interested in health or medicine. Born to an elite family in pre–Civil War Alabama, as a child Gorgas fled Virginia barefoot as it burned, and so decided early in life that he would be a fighting man.26 Getting into West Point was his “burning ambition,” according to his biographer, but somehow the tall, soft-spoken Gorgas, even with all his connections (his grandfather had been the governor of Alabama, his father presided over the University of the South), couldn’t secure a place there. This was a terrible blow, but the determined Gorgas discerned a back door: the military needed doctors.27

  His father had been “aghast” at Gorgas’s plans to enter medicine, even if it was just a ruse to get into West Point. A Gorgas going to medical school was sort of like a Kennedy driving a taxicab. This was decades before the age of antibiotics catapulted doctoring into a high art, before regulatory authorities required doctors to go through medical training, before Johns Hopkins opened its first medical school and required that its graduates accomplish college degrees and four years of training. Doctors were considered quacks, and medicine a joke—not surprising, really, given that medical treatment for even the most terrifying scourges such as yellow fever, which regularly rampaged the South during Gorgas’s childhood, consisted of whisky, brandy, and cigars.28

  By the turn of the century, Gorgas had a medical degree and a post in the army’s medical department.29 He first distinguished himself in the fight against yellow fever in Havana, Cuba, where he worked under Major Walter Reed, whose experimentation had established mosquitoes as the disease’s vector. Having survived yellow fever in Texas, Gorgas enjoyed complete immunity to the virus. He didn’t quite believe Reed’s proposition about the bugs—Gorgas’s anti–yellow fever method to date had involved burning down whole camps—but like any good soldier, he would not let personal belief eclipse the requirements of duty. Gorgas considered it his responsibility to “take precautions in this direction,” and so he divided Havana into manageable districts, surveyed every house and family, and, with military precision, methodically destroyed every place he could find—every puddle, every open bucket—where the alleged mosquito enemy might find succor. By 1902, yellow fever was gone from Havana.30

  With the Havana victory under his belt, Gorgas was the obvious choice for the job of attacking Panama’s mosquitoes, whose role in transmitting malaria was by then six-year-old news. But most of the people with authority over the canal had yet to be convinced that mosquitoes, rather than smelly miasmas, transmitted the disease. President Roosevelt appointed his most accomplished engineers, the men who built the Washington Monument and the Illinois Central Railroad, to “make the dirt fly” in Panama, and pointedly did not name a medical specialist to the commission overseeing the canal’s construction. Had it not been for a reference from a friend of Roosevelt’s, Gorgas’s assignment might never have happened at all.31

  As a result, besides the powers of his considerable Southern charm (nurses called him “Dr. Gorgeous”), Gorgas had little real authority in Panama. He and his colleague Joseph LePrince arrived in Colón with a staff of just seven. They found stagnant water festering over the dilapidated town, and frame houses resting on piles above lagoons of green slime. Mosquitoes flitted every where: up and down the line of the proposed canal; well into Portobelo; teeming from rainwater barrels, streams, ponds, and swamps. And while there was no yellow fever to be seen (there were few foreigners in Panama to harbor it), the pallid hues and grotesque deformities caused by malarial parasites and mosquito-transmitted filarial worms abounded in the locals.32

  Attacking Panama’s resilient mosquito vectors would be a much bigger job than the assault on the yellow fever mosquito, Aedes aegypti, in Havana had been. Aedes aegypti lay its eggs exclusively in artificial containers of water found around human dwellings, making the species a pitifully soft target. In Panama, malaria burrowed as deeply into the isthmus’s ecology as the spooky mangroves, whose roots rendered miles of Panama’s swamps and shorelines impenetrable. Anopheles albimanus, which transmitted most of Panama’s malaria, lay its eggs in fresh or salty water, in sunny puddles or lagoons, and fed on the blood of man or animal (although it particularly fancied horses), either indoors or out. No single point of attack could deter it for long. And like any creature well embedded in an ecosystem, Plasmodium enjoyed other alliances: the indiscriminate biters Anopheles albitarsis and Anopheles punctimacula, the saltwater Anopheles aquasalis, and the jungle mosquito Anopheles darlingii all ferried it into new bloodstreams when A. albimanus could not.33

  Gorgas and his team set up shop in one of the French-built hospitals still languishing on the isthmus. Mosquitoes hatched from the potted plants in the hospital’s elaborate gardens and sailed into the wards through unscreened windows to feed on the patients and their caretakers. Their tiny bodies covered the walls and doors of the hospital, each panel speckled with more than fifty at a time. After the sun went down, the staff could tend to patients only if a colleague stood beside them furiously fanning the mosquitoes away, while the night-duty nurses wilted, mummified in citronella-soaked bandages. Locals avoided the malarious hospital as much as possible.34

  Gorgas immediately cabled Washington with a list of supplies. He requested great volumes of insecticidal pyrethrum and sulphur for fumigating, two tons of newspaper to seal the buildings from mosquitoes, masses of wire screening, a slew of workers, including at least twenty inspectors and one hundred trained nurses, plus start-up funds for a research lab.35

  At first it seemed to Gorgas’s team that their list of supplies must have glued itself to some “invisible spot” in Washington. They waited (“with the patience of angels,” as LePrince put it). Finally, responses from Washington trickled in. Why was Gorgas sending so many costly cables? the officials in D.C. asked. He should use the mails instead. Wire screening and a research lab were out of the question, they informed him. As were the giant quantities of materials and labor. He’d get a quarter of the required volume of pyrethrum and sulphur, along with eight of the requested twenty inspectors and forty of the requested one
hundred nurses. If he needed more workers, he’d have to “get a few niggers,” they told him. Washington certainly wouldn’t be sending any newspaper, either. In that case, they’d misunderstood Gorgas’s meaning; they’d thought the good doctor wanted reading material.36

  Dressed down, Gorgas dolefully made his rounds throughout Panama, watching the mosquitoes hatch and getting an earful of scorn from the engineers as he did. With his paltry supplies, Gorgas’s staff focused on oiling puddles to smother mosquito larvae and fumigating the few buildings they could—in other words, making dirty puddles dirtier and stinky buildings stinkier. The canal commissioners were not impressed. “It’s silly to spend all this money just to kill a few mosquitoes,” one said.37 “A dollar spent on sanitation is like throwing it into the bay,” another added.38 “On the mosquito you are simply wild,” another said. “All who agree with you are wild. Get the idea out of your head.”39

  Gorgas’s assault on Panama’s mosquitoes began in earnest only after yellow fever broke out. Three quarters of all the Americans on the isthmus, including the chief engineer, fled. “A white man’s a fool to go there,” one refugee said, “and a bigger fool to stay.” The Canal Commission members who traveled back and forth from Panama to the United States took to bringing their ornate coffins in tow, just in case.40

  Alarmed, Roosevelt showered Gorgas with resources to do something about the mosquitoes.41 (The canal commissioners and William Howard Taft, Roosevelt’s secretary of war, still were not convinced; Taft complained that Gorgas had “no executive ability at all.”) Soon Gorgas commanded a staff of 4,100 workers, a budget of $250,000, and the entire U.S. supply of sulphur, pyrethrum, and kerosene oil.42