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

Introduction

“Has Malaria Disappeared?” one hopeful southern medical editor asked at midcentury. “Malaria Reduced to the Vanishing Point,” proclaimed the U.S. Public Health Service in jubilant answer.¹ American malariologists had good reason for breaking open the champagne in 1950.Malaria, a disease that had plagued the country from its earliest years as a colony, was gone. Passed from person to person by the bite of the female anopheles mosquito, malaria parasites cause debilitating fevers and sometimes death. Malaria was a significant disease in American history, one that shaped southern and western history in particular through its impact on labor patterns , mortality rates, and settlement choices. Its demise was certainly cause for celebration. Even though it is mostly a memory in the United States, malaria remains a major health disaster internationally. Malaria parasites killed millions of people during the 1990s, and sickened hundreds of times as many, and there is no prospect that these numbers will improve soon. As one international committee report put it, “The outlook for malaria control is grim. The disease . . . is present in 102 countries and is responsible for over 100 million clinical cases and 1–2 million deaths each year.” Far from optimistic , the committee reported that the situation is growing worse, for “efforts to control malaria have met with less and less success.”² This scourge has survived major international campaigns that were armed with insecticides against the vector and antibiotics against the parasite. Resistance to both weapons has emerged, and unless researchers create an effective vaccine, there is no hope on the horizon that malaria will retreat as a major world pestilence. Most Americans think of malaria as a tropical nuisance, if they think of it at all.It is a problem for vacationers or missionaries or adopted children from foreign lands, not a part of their everyday lives.But malaria was once very much a prominent American disease, common in some areas as late as the 1940s. Cases are frequently imported into the United States today, which is not surprising since something like 40 percent of the world’s populationlivesinmalariousareasandinternationaltravelisso fluidandrapid. 1 Introduction Rarely, however, do new cases arise within the United States; imported parasites are usually contained within their host bodies.When indigenous (nonimported) cases do occur, it is headline news.³ Malaria, once a painfully frequent presence in many parts of the United States, has become a tropical exotic.It has emerged as one of the diseases that separates thefirst, industrialized world from the third, developing sphere, or as some would have it, the “North” from the “South,” globally conceived. The disappearance of malaria is one of the hallmarks of America’s rise to world leadership , domination, and prosperity. Why did malaria once flourish so readily in the United States, and why did it disappear? If it was a major plague on the nineteenth-century frontier , as it was, why is it a distinct anomaly in Omaha today? If there were well over a million cases of malaria in the South during the Great Depression , why were there fewer than a hundred in 1950? The first answer that comes to mind is that some combination of determined disease fighters and public health technology conquered malaria.But this is not what happened ,eitherinthenineteenthcenturyorinthetwentieth.Accurateknowledge of the disease vector, the fact that mosquitoes spread malaria, was not at hand until 1897, so the retreat of malaria from the nineteenth-century frontier cannot be explained by deliberate public health action that speci- fically targeted the disease. And while the twentieth-century malaria picture was made much more complex by the existence of that etiological knowledge and measures based upon it, major socioeconomic factors, and not steps taken directly against parasite and vector, deserve the major credit for malaria’s disappearance. Most versions of malaria’s career in the United States attribute its demise to the U.S.Public Health Service’s DDT campaign of the 1940s.It is a plausible explanation, but at most it accounts for only a tiny percentage ofmalaria’sreduction,sincemalariahadlargelydisappearedbeforeitcould be eradicated by DDT. DDT did finish off the last pockets of disease, but it cannot explain the rapid drop in malaria prevalence that occurred a few years before the spraying started. Understanding what brought about that dropmeansweighingthevariouspriorpublichealthefforts,aspectsoflifestyle and poverty, and finally issues of geography. My solution to the mystery , tied heavily to geography and insect migration behavior, is supported but not proven by the evidence.The reader is warned that, like Robertson Davies’s thematic...