Malaria: Poverty, Race, and Public Health in the United States (review)

Today in the developed world people do not often worry about malaria, though this mosquito-borne illness still produces hundreds of millions of cases and kills millions of people in the developing world. How did this dissonance come about? In Margaret Humphreys's book, the divide between development and disease is a causal relationship: Moving out of poverty shifts populations away from illness. Humphreys makes this case compellingly for the United States during the nineteenth century and the first half of the twentieth century. Using malaria as its central example, the book moves on from Humphreys's earlier book, Yellow Fever and the South (Johns Hopkins University Press, 1992), to treat the professional and institutional development of public health structures and the role of race and poverty in disease.

Malaria—an endemic and often debilitating and deadly disease in much of the United States in preceding centuries—was essentially absent from the country by 1950. What brought about the decline and fall of this persistent pestilence? Even before the deployment of DDT against mosquitoes in the 1940s, malaria was in retreat in the United States. Humphreys offers a detailed, tightly reasoned story, but as she writes: "My solution to the mystery, tied heavily to geography and insect migration behavior, is supported but not proven by the evidence" (p. 2). Nevertheless, as she promises, her book leaves us all "wiser at the end." Humphreys argues "that malaria has to be understood within a web of socioeconomic as well as biological influences" (p. 49). The book—an attack on the concomitant evils of poverty—teases apart the threads of poverty and disease to the greatest extent possible. Humphreys examines agriculture and land use, labor practices, nutrition, housing quality and density, and comorbidities, such as hookworm, tuberculosis, and pellagra.

The critical variable in malaria transmission in the American South was the proximity between people and the wetlands where the mosquito vectors bred. In the nineteenth century the solution to the malaria problem often lay in the transformation from frontier life to "civilization . . . with its tighter houses, better drained towns and fields, abundant food, and access to quinine" (p. 36). Antimalarial drugs, such as quinine, could play only a supporting role at best. Humphreys emphasizes that people living in malarial localities moved their homes away from mosquito-breeding, miasmal wetlands as they prospered economically. Tight houses, with screened windows, located away from mosquito-breeding areas, worked against malaria transmission. In later years, advances in technology, such as insecticides for house spraying (e.g., pyrethrum) were deployed.

Humphreys provides an edifying and convincing account that comfortably blends scientific and literary sources and gives a hearing to diverse voices from many sides of the malaria problem. She parses these into three perspectives—medical, popular, and parasite—that create "a maze of interlocking and shifting influences" (p. 3). Using fiction, travel narratives, and oral histories as sources, she pursues a cultural history of malaria. This is successful and gives a different feel to each chapter as the reader hears diverse perspectives emerge from the sources. Humphreys also explicitly draws on the work of Erwin H. Ackerknecht. Both Ackerknecht and Humphreys in turn—though writing some fifty years apart—draw on some of the great twentieth-century malariologists, such as Marshall Barber, Mark Boyd, and Lewis Hackett of the Rockefeller Foundation and Tulane's Charles Bass.

The key decades for malaria in the United States were the 1930s and 1940s. Although New Deal programs directly attacked malaria with mixed results—the Tennessee Valley Authority being the most successful—it was the indirect impact of federal programs that proved crucial. Federal incentives increased the scale and mechanization of agriculture, forcing sharecroppers and tenant farmers off the land. The displacement of labor from rural employment in the South to urban employment in the North and West, away from the land and into the newly expanding war industries, broke the chain of transmission. All of this, of course, happened...