Vaccination is a bulwark of public health but it is a small group of diseases that can be vaccinated for. With RTS,S malaria may be about to join the club
Malaria is one for the most pernicious infectious diseases on Earth. It kills up to a million people every year, most of them African. In non-fatal cases the debilitating consequences of infection, like stunted growth and anaemia, denies millions of children the chance to attend school and prevents parents going to work each year.
Spread by Anopheles mosquitoes, battling this rapacious blood parasite is a monumental challenge. However there is renewed hope. After nearly 20 years of research costing hundreds of millions of dollars, there is a promising vaccine candidate. This childhood jab, called RTS,S, passed a milestone in January this year. It has reached the target number set for infants and children enrolled on phase three trials. This is the final stage a drug or vaccine goes through before going on general release.
Although the final results are not expected until late 2014, the trials mean almost 15,500 infants and young children will receive what could be a lifesaving shot. If these final round of trials are a success then RTS,S will be a hitherto only dreamed of weapon against malaria possibly saving lives within the decade
The cost of malaria
Malaria is closely linked to poverty. Broadly speaking where malaria is at its strongest, economic development is at its weakest. The prices resource strapped governments and their impoverished citizens must pay for anti-malarial drugs and mosquito controls are only part of the cost of this disease.
The school and work days that are lost to malaria inhibit the development of economies both on the household and national scale. Hence, malaria plays a considerable part in ensnaring people in a cycle of disease and poverty.
While a seemingly intractable problem in Africa, malaria has been successfully eradicated in the developed world. The wealth of industrialised economies of course fuelled the fight against disease, and self-interest ensured the money was spent, but it is also important to consider the impact climate has on how the parasite spreads.
In order to infect someone the malaria micro-organism must first be eaten by a mosquito in a blood meal from an infected person. To pass down the hypodermic-like mouth-parts of the mosquito into the blood of the insect’s next bite victim, the microbe must move from the mosquito’s stomach to its saliva glands.
To make this anatomical migration the parasite must morph into a new form, transitioning to a new stage in its life cycle. This is called the extrinsic incubation period.
The colder the ambient temperature the longer the extrinsic incubation period lasts. According to the Centre for Disease Control and Prevention it can range from 10-21 days. Malaria parasites cease developing in the mosquito altogether if the temperature drops below 16°C and in any case, mosquitos stop biting at very low temperatures.
In temperate regions of the world where temperature can drop very low, malaria transmission is therefore curtailed to short seasons. With a shorter season comes a lower burden of disease. Therefore there is less suppression of economic development and the disease is easier to combat.
Malaria in Italy
The relative advantage of tackling malaria in temperate climes prompted the great Italian zoologist and malariologist Giovanni Battista Grassi to declare it a “giant with feet of clay”; beatable with the right interventions.
At the turn of the 19th Century, the disease was endemic in Italy, killing an average of 15,000 Italians a year between 1887 and 1922. At this time, Grassi was in his ultimately fruitless race with Ronald Ross to be first to discover how malaria is transmitted.
In 1925, responding to this death rate and with a view to reduce Italy’s reliance on imported quinine, Benito Mussolini authorised an horrific investigation. Grossly unethical in all respects, the research sought to answer: can mercury be used as an anti-malarial?
In the pursuit of an answer stalwart fascist Giacomo Peroni committed heinous crimes in the name of medical science. He actively infected people with malaria, withheld quinine which was known could have saved them, and administered mercury salts to half of his victims, leaving the other half to die as a “control group”.
The records of Peroni’s investigation are incomplete. While the control group perished the fate of his treatment group remains largely unknown. He declared his work a resounding success. A smaller repeat investigation found the toxic mercury to be, astoundingly, completely ineffective either as prophylaxis or therapy.
Taking the land back
On 24 December 1928 Mussolini unveiled Mussolini’s Law; a 14 year land reclamation programme with a budget of ~7bn lire, about €5bn at 2007 value. Mussolini’s Law aimed to turn the Kingdom’s swamps and marshes into cultivable, productive farmland.
The association of marshes with malaria runs back before the mosquito was named culprit by Grassi and Ross. As far as the Romans who believed mal aria, or bad air, was responsible for the disease.
Mussolini’s land reclamation programme was inherently political; at 7bn lire it was not just the public health, there had to be a grander scheme. Eradicating malaria and turning marshland into productive farmland had clear economic and social benefits. However Mussolini’s motives ran into demographics, social engineering and man’s dominion over nature.
Specific attention of Il Duce’s grand land reclamation was paid to the Pontine Marshes, a 75,000 hectare (750,000 sq. km) marsh about 30 miles south of Rome. The Pontine Marshes that Cicero himself declared “neither pleasant nor healthy”. The Pontine Marshes had thus far resisted Roman emperors, Popes and the Liberal governments of post-unification Italy.
The Lepini Mountains bordered the marshes and formed their entire western watershed. Sand dunes and the embankment of the Rome-Naples railway prevented the snowmelt and rainfall from draining into the sea. The whole area was a flat series of pools and ponds full of Anopheles maculipenis mosquitos, malaria’s insect vectors.
In 1928 the area could support a stable population of just over 1,500 people. The Italian Red Cross estimated 80 per cent of those who spent a night in the marshes during the summer malaria season would contract the disease.
La Bonifica Integrale
The reclamation of the Pontine Marshes, la bonifica integrale (integrated reclamation) was divided into three steps: bonifica idraulica (hydrological reclamation), bonifica agraria (agricultural reclamation) and bonifica igienica (sanitary reclamation).
The bonifica integrale “was meant to tame or dominate nature” says John Foot, professor of modern Italian history at University College London. He continues: “It was almost biblical on its scale; moving people, moving water, moving the earth.”
In 1930 columns of men, 50,000 members of World War One veterans association the Opera Nazionale Combattenti (ONC), were mobilised and marched into the swampy wastes. Together with squadrons of caterpillar-tracked earth movers the workers set to transforming the land.
They dug a drainage network of canals, channels and ditches so comprehensive that, at 16,000 kilometres, if laid end to end it would stretch from London beyond Sydney.
They built 18 pumping stations, impianti idrovori (literally ‘water eating’ plants), to compensate for the billiard table flatness of the region. The largest was capable of sucking in water from 9,000 hectares of land, an area larger than Manhattan.
At la bonifica integrale’s peak in 1933 it employed nearly 125,000 workers. As the swamp drained and slowly dried the programme moved into the agricultural phase. These men created the infrastructure for a new region of Littoria, now Latina. They laid over 1,000 kilometres of roads, strung more than a 1,000 kilometres of telephone wire and nearly 650 kilometres of electrical cable.
Five new cities were thrown up. “They created the most extraordinary towns from nothing, in the middle of nowhere” says Prof Foot. “Classical roman with marble, very well planned. They built Sabaudia in just 253 days.” These cities, arranged around the region’s eponymous capital, each acted as an administrative hub for smaller satellite villages. The villages were themselves centres for individual farmsteads.
Littoria was to be home to around 60,000 settlers. Mussolini transported loyal fascists from the Veneto in the north, around Venice. These internal migrants were brought in partly to help maintain the farmland and drainage system, to prevent the land turning back into marshland.
The ONC laboured and the settlers began scraping their living from the newly emerged farmland. The direct action against malaria made up the third prong of Mussolini’s assault on the marshes.
The bonifica igienica was a public health programme; quinine was distributed through regional health centres and schools. The mosquito larvae were directly controlled by spraying larvicidal treatments on the remaining standing water. Canals and channels were stocked with the larviphorous mosquitofish – Gambusia affinis. The incidence of fever was recorded and the personal information of each case of malaria was logged for analysis.
However beneath the public health and agricultural rationale for reclamation the basic ideology of fascism thrust at a different objective. The land reclamation was part of a long term plan to develop and ruralise Italy.
Ideology, femininity and taking the fight to ‘them’
Mussolini’s regime believed there was a population crisis in Italy. The true fascist stock was dwindling; diluted by the liberalism and industrial capitalism of urban life. So urbanisation of the population had to be checked. “The architecture was modern but the focus of the bonifica was the family farms,” Prof Foot explains. “Looking back and looking forwards, modernisation and ruralisation. That is the dichotomy of fascism that made it so attractive to all the different social classes.”
The internal colonisation was from the north to the south. It was a bid to socially reengineer Italy. The reclaimed land was to be populated with subjects loyal to Mussolini, to create a rural fascist utopia.
At the core of the modernising ruralisation lay the need to dominate nature. The fascists viewed weakening, sterilising malaria as feminine. It was a threat to the masculine fertility of the people and their Kingdom. Therefore the marshes with malaria at their heart were blamed for the supposed decline in the purity of Italy’s population.
This social engineering chimes with the need to unify, to bring together the people under the totalitarian authority. To unify the population to work together and do Il Duce’s bidding meant there had to be a common foe. Malaria became the enemy; it threatened production and progress and had to be vanquished. This principle has uncomfortable echoes in the neo-conservative need for an arch-nemesis, the “them” that the “us” can rally against.
Failing at the brink of success
Clearing the Pontine Marshes brought some success in the fight against malaria. The population of the area grew more than 11 times from 5,500 to 62,075 between 1930 and 1934. In these four years the cases of malaria per 100 people dropped from nearly 50 to just over 15. In the subsequent five years the population fell to 45,000 but cases per 100 people dropped to less than 0.1.
However the War years brought depravation and disease back to Littoria. Doctors, nurses and quinine were called away to the front, able men were conscripted, and the farmlands and drainage network were rundown. The precarious hydrological and ecological balance constructed in the region tipped back to marsh-land.
As the War wore on and Mussolini’s power waned, the Nazi’s occupying Italy turned on their one-time allies. The barbarism meted out in the “total war” on the Italian civilians intensified as the Allied powers advanced through Europe.
Hitler’s forces, retreating through Littoria, reversed the pumping stations and stopped up drainage canals. A move which Frank Snowden, professor of history at Yale University, describes as “the only use of biological warfare in 20th century Europe”.
The reclaimed land regressed back to its sterile, malaria ridden natural state. Cases and deaths exploded among the local population. This criminal act, while tragic for the Italian civilians, failed to halt the oncoming British and American troops.
Fascism failed to eradicate malaria from Italy’s shores. Plasmodium falciparum malaria was defeated in 1952 after a five-year, nationwide programme using DDT to destroy the mosquito. It was not until 1970 that the World Health Organisation declared Italy free from malaria, when Plasmodium vivax was eventually overcome.
A warning from history
The fascists may have failed to stamp malaria out but they did bring it down to a shadow. The fight against malaria in Italy was possible because of its climate but also the investment of money and man-power.
It is possible were it not for the horrors of the Second World War Mussolini’s bonifica could have cleared malaria out of the Pontine Marshes completely. Similar efforts in other Italian malaria zones could have succeeded too and eventually the Italians could have been free of the disease.
The RTS,S vaccine kindles hope for a brighter future in the fight against malaria in Africa. However it is like a forest fire; beaten down in one place only to spring up in another. Even when it looks like it is out, all control efforts must be maintained. If you stop dousing the ashes for a moment an ember could spark the blaze into destructive life once more.
The need to continue the various different control methods in malaria hot-spots is paramount. It is clear that drugs alone will not suffice. The monumental efforts to expel the disease from Italy in the last century shows bed nets, insecticides, drugs and vaccines as well as improvements to housing and better land use will all be needed in this century. The eventual eradication of malaria is possible; however there is still a mountain to climb.
Sachs, J., & Malaney, P. (2002). The economic and social burden of malaria Nature, 415 (6872), 680-685 DOI: 10.1038/415680a
Capanna E (2006). Grassi versus Ross: who solved the riddle of malaria? International microbiology : the official journal of the Spanish Society for Microbiology, 9 (1), 69-74 PMID: 16636993
Coluzzi M (1999). The clay feet of the malaria giant and its African roots: hypotheses and inferences about origin, spread and control of Plasmodium falciparum. Parassitologia, 41 (1-3), 277-83 PMID: 10697869
Professor Arturo Castiglioni (1927). Nova et Vetera BMJ, 2 (3475), 278-279 DOI: 10.1136/bmj.2.3475.278
Caprotti, F., & Kaika, M. (2008). Producing the ideal fascist landscape: nature, materiality and the cinematic representation of land reclamation in the Pontine Marshes Social & Cultural Geography, 9 (6), 613-634 DOI: 10.1080/14649360802292447
CAPROTTI, F. (2006). Malaria and technological networks: medical geography in the Pontine Marshes, Italy, in the 1930s The Geographical Journal, 172 (2), 145-155 DOI: 10.1111/j.1475-4959.2006.00177.x
CAPROTTI, F. (2007). Destructive creation: fascist urban planning, architecture and New Towns in the Pontine Marshes Journal of Historical Geography, 33 (3), 651-679 DOI: 10.1016/j.jhg.2006.08.002
First Image Credit: Andrew W. McGalliard via Wikimedia Commons
Second Image Credit: U.S. CDC via Wikimedia Commons
Third Image Credit: Stimoroll via Wikimedia Commons
Fourth Image Credit: Wikimedia Commons
Fifth Image Credit: Wikimedia Commons
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