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

5 “A Ditch in Time Saves Quinine?”

Chapter 5 “A Ditch in Time Saves Quinine?” 94 The Great Depression decade was a pivotal period in the history of American malaria.While the first half of the 1930s saw a massive surge in malaria cases, the disease had almost disappeared by 1940. These years offer fertile material for a historical analysis of the causes of malaria’s progress and retreat. It was a time of major socioeconomic turmoil, and the decade saw the implementation of federal relief efforts on a scale never before attempted in the United States.And malaria never recovered from the nadir reached by 1940.During the last quarter of the 1930s, something irrevocable happened to banish the disease. In 1930, the South remained desperately diseased and impoverished, and its public health apparatus was accordingly underfunded.Malaria had declined over the 1920s, but it was still a visible and troubling presence, and hope was slim that internal monetary resources would appear to aid in its control. There was broad agreement that malaria drained the economy of productive workers. There was equally broad agreement that the South’s taxpayers could not afford to pay for the massive effort that would be needed to eradicate malaria from the rural South using the available methods. Even if legislators had been willing, the burden of other diseases (pellagra, hookworm, tuberculosis, and syphilis) hardly made malaria special enough for particular attention, and the pervasiveness of poverty meant that precious few tax dollars were available to spend. Cotton culture bred a wretchedly poor worker class that in turn occupied shabby housing in the swampy countryside. How could change, and increased health, be brought to this system? Or as one reporter concluded, after surveying health conditions in the impoverished rural South in the 1920s, “The solutions to the problems of malaria and hookworm are quite clear—draining, screening, furnishing shoes to the people, and teaching them cleanly habits.” But could it be done? Actually, he concluded, “the whole thing is as simple and easy as it would be for a one-armed man to empty the Great Lakes with a spoon.”¹ Malaria in the 1930s As in the third world countries that the South of this era resembled, aid had to come from the outside, in the form of charitable contributions or governmental interventions. We have seen the role that the Rockefeller Foundation played in some of the earliest antimalaria campaigns. The USPHS was also active, to the extent that its funding allowed. The Rockefeller Foundation eventually pulled out, deciding to target international health problems instead.The USPHS saw its budget cut by the penurious Coolidgeadministrationinthe1920s,thenloweredstillfurtherbytheearly years of the Great Depression. Other philanthropic agencies, who would otherwise have been willing to continue their work in the South, had to withdraw as their investment income crashed along with the stock market in 1929. As desperate poverty settled over the South in the 1930s, malaria made a dramatic comeback, reaching incidence levels not seen since 1912. Surprisedpublichealthofficialshadnotexpectedthespike.Bytheearly 1930s the prevalence of malaria in southern “urban” areas (population greater than 1,000) had declined markedly, thanks to drainage and larvicidal efforts, and it appeared to be declining in rural areas as well.Although not subject to the dust storms of the prairie states, the southern region did experience drought, with a resulting drop in the anopheles population. Consequently, the years 1930-32 marked a new low in malaria mortality rates. Malariologists at the state and national level began to sound rather smug. As a Georgia public health official summarized, “We have passed throughadarkperiod . . . andattimesourproblemsseemedalmosthopeless . We are now emerging from this period and feel very optimistic.”² They had the disease on the run and felt that it was only a matter of time before it was gone altogether.“[M]alaria in Mississippi is slowly becoming avanishingdisease,”claimedstatisticianFrederickL.Hoffmanin1932.The future indeed looked bright, although the era’s economic desperation prevented total equanimity.³ Imagine the dismay when the malaria mortality rate soared in 1934 and 1935.⁴ This resurgence destroyed all hopes that the disease would gradually fade away, for it had come back with a vengeance. Tulane epidemiologist Ernest Carroll Faust kept track of malaria mortality data, gathering, publishing, and analyzing each state’s reports yearly.In 1945 he presented a cumulated version of his results, beginning with 1929.⁵ Information about disease-specific mortality before that year was incomplete, as not all southern states participated in collection and reporting.Faust’s table indicates that malaria mortality...