The Fever

Recently finished The Fever by Sonia Shah. I bought a paperback copy at Ikirezi Bookshop after my first bout of malaria in 2015, but then got distracted. After a hideous month in October where I was floored by it twice, I decided to revisit the topic. It's always interesting to know what's going on inside you, and malaria is a particularly nasty li'le critter. It crawls inside your red blood cells, feasts on your haemoglobin, then bursts out of them alien style, leaving your spleen to deal with the fall-out.

I posted this before, but Shah's TED talk is a really good summary of the book in a nutshell.

It's a fairly concise read, but I took so many notes. She's got a really easy style to read, turning something quite technical and medical into a story of primordial genetic battles and human cost. At times it turns quite graphic.

Every morning in Panama I would awaken with some unexpected swelling from the mosquitoes’ nighttime blood feasts: under my eye one day, on my eyelid the next, on the palm of my hand. Smashed mosquitoes, glued to the surface with their own internal juices, dotted the walls.

The book starts out with a really good quote:

Man ploughs the sea like a leviathan, he soars through the air like an eagle; his voice circles the world in a moment, his eyes pierce the heavens; he moves mountains, he makes the desert to bloom; he has planted his flag at the north pole and the south; yet millions of men each year are destroyed because they fail to outwit a mosquito.  — Paul F. Russell, 1931

I thought it was funny when she was talking about going to swot mosquitoes and deliberately - sort of - missing. From a Jain family (see the video) there was part of her averse to killing living things no matter how annoying they are. I was vegetarian until my early twenties and also have that dilemma of wanting the mosquito gone, but not wanting to be the one to make it go away. If they're inside my mosquito net, I'm afraid they're doomed nowadays, but if they're outside, it's about a fifty-fifty whether I actually hit them after lifting my hand.

A flimsy mosquito landed gently on my forearm. A familiar spike of rage rose as I watched, incredulous, as the insect prepared to puncture my skin with her proboscis. How dare she! Instinctively, my hand snapped up. Somewhere inside that cold-blooded, brittle body lurked entities whose exertions explained the making of rich and poor, sick and healthful. My hand came down a bit slower for the passing thought, and I brushed the mosquito away like a crumb. Its delicate legs snarled together, pitching the insect’s body forward at a steep angle. Mangled, it skittered off my arm awkwardly as I watched, my vestigial Jain sensibilities slightly horrified. Finally it reached the precipice, where it somehow took flight and vanished.

You might find this poem, Death of a Cockroach entertaining. One man's remorse over dispatching a household pest.

Naturally, I was engrossed in the early parts of the book which are all about how the disease spreads, breeds and takes over your internal organs. It really is a very complex disease, and it was fascinating to think of it working its way through my body. It also explained a specific pain that I had for a couple of weeks when the resurgence happened. I think it was my spleen, which I didn't realise was so involved in clearing out the dead blood cells. It's one of those organs I couldn't point to until I looked it up.

First, the sporozoites retreat to the liver, where they spend a few surreptitious days shifting, regenerating, dividing, and generating again, secretly transforming into an army of fifty thousand parasites in a new form capable of infecting red blood cells: the merozoite. In the next stage of the invasion, the merozoites pour into the bloodstream. They are cleverly disguised inside the liver cells they’ve gagged and murdered, but an epic battle ensues nevertheless, and the body’s immune fighters slaughter thousands. It isn’t a perfect victory. If a few stragglers in this marauding horde manage to escape, they latch onto red blood cells, and within moments penetrate the cells’ interior. There, they quietly feast on haemoglobin, and a new round of shifting, regenerating, dividing, and generating ensues. Some transform from tiny ring-shaped beings into fat, rounded creatures and unleash a wave of progeny. When nothing is left of the former oxygen-carrying cell besides a stream of waste and a bulge of fattened parasites, the parasites burst out of the cell and rush out to invade and consume a fresh crop of cells. Others quietly shape-shift into the male and female forms called gametocytes and lie in wait inside their hijacked blood cells. With any luck, they will be picked up by another bloodthirsty Anopheles mosquito.

*

Almost all of Plasmodium’s manoeuvres inside the body occur in utter secrecy. When it slips into the body, while it hides in the liver, and even after it emerges into the bloodstream and attacks blood cells, there is no itch, no rash, no sweaty forehead that belies the infestation roiling within. It is only after malaria parasites rupture out of their hijacked cells, well into the parasitic invasion, that the infected person feels sick. The waste from the parasite’s haemoglobin feast leaks out of the destroyed cells, and that tiny spike of poison triggers a round of detoxification, throwing the victim into a high fever, followed by chills and shivering. When the waste disperses, the fever passes, and for several days there might be no symptoms at all—until the parasite finishes gobbling up its next batch of haemoglobin and explodes again in search of more, triggering another attack of fever and chills. The parasite’s steady consumption of its victim’s blood drains him of vitality, making him easy pickings for other pathogens of various ilk. But while the parasite grows inside, aside from an enlarged abdomen — the spleen of the malaria-infected can swell to twenty times its normal weight while clearing the body of dead cells — its passage remains obscure. All the while, mosquitoes will bite, and imbibe the parasite roosting in the blood, and the cycle continues.

It was also interesting that the more people I started speaking to about malaria, the more have told me that fever didn't play a major role. A raging fever is certainly the norm, but not always, and malaria presenting without fever seems harder to diagnose early. Partly because the patient doesn't automatically think malaria, and partly because fever indicates more parasites releasing into the blood, making it easier to spot in a test. Apparently, tests are difficult to undertake and often come back clean when the person is actually infected - which is what happened to me. What I experienced is apparently quite common.

Other things that I learned included that the malaria strain p. vivax, which preceded p. falciparum in Africa and is now common in Asia and Latin America, was driven out of most of Africa by an evolution in local people's blood cells mutating so that it could no longer infect them. This defence was unfortunately then bypassed by a more deadly strain, p. falciparum, which recent studies believe we originally contracted from gorillas. Sickle cell anaemia is another form of mutation that developed as a resistance to malaria. The crescent shape of the cells can cause life-threatening illness and chronic pain, but can also provide immunity to malaria.

It's long been whispered among expats here that if you've lived in-country for many years, you'll build some resistance to malaria. I was never sure whether to believe this or not, but it turns out it's true. Like other diseases, your immune system can recognise and guard against forms of malaria that you get. So, having malaria a few times can make you resistant to future outbreaks, which is why children in Africa who get malaria a lot don't get it as much in adulthood. The bad news is that malaria mutates and evolves extremely rapidly, so if you leave the country for a few years and return, you might have lost your immunity because your body hasn't encountered the new strains that now exist.

This disease has thousands of years of experience in survival:

Ancient Greeks understood malaria as a seasonal scourge that arrived during harvest time. The physician  Hippocrates  described  it  as  a  disease  common  around  swamps,  while  the poet  Homer  referred  to  malaria  when  he  decried  Sirius  as  an  ‘evil  star’  that  was  the ‘harbinger of fevers’. The ancient Chinese called malaria the ‘mother of fevers,’ while in India thirty-five hundred years ago it became known as the ‘king of diseases,’ personified by the fever demon Takman.

Some ancient remedies included honeysuckle in wine, eating the liver of a seven-year-old mouse, wearing an abracadabra charm, or chowing down on bedbugs with eggs and wine, which was recommended in Roman times. You could also wake at dawn for three mornings in a row, facing a window which you were supposed to shut suddenly whilst reciting a prayer. For men, having sex with a woman who had just started menstruating was also recommended. Lucky woman. If you couldn't find a bleeding woman, 'energetic bloodletting' was also acceptable. Failing all else, go prostrate yourself at one of the three temples in Rome dedicated to the demon goddess of malaria, Febres.

It has since been found that cloves, cinnamon, basil, nutmeg and onion lessen the parasite's appetite so may slow its progress. There's also some evidence to suggest that coffee might be beneficial in resisting malaria, as coffee-drinking French colonists suffered less from it than tea-drinking English ones.

Another thing I found fascinating was how widespread malaria once was in America and the UK, with Kent and Essex being the most malarial counties in Britain.

It was known for centuries that the cinchona tree is an effective remedy against most forms of malaria, as the bark contains quinine. However, staunchly protestant Europeans refused to touch it because they considered it 'Jesuit powder,' the Jesuits being the ones to have discovered its beneficial properties. 

Hence, in an amusing turn of events, Oliver Cromwell, renouncing this Catholic witchcraft, proceeded to die of malaria.

The major breakthrough which has impacted my life was the discovery of artemisia annua, or Sweet Wormwood. Whilst looking for potential cures in the fight against quinine-resistant malaria, which falciparum is in my part of East Africa, Chinese researchers found a book titled Fifty-two Prescriptions dating back to 168 BC. It cropped up again in 340 AD as a 'bitter tea.' The Chinese decided to try it out and between 1980-90 slashed malaria rates from two million to ninety thousand. The west, however, fucked it all up by attempting to over-heat the compound, destroying its medical properties and declaring it useless. Because of this, it took decades to accept that the active ingredient, artemether, actually was a full-on cure for p. falciparum and bring it to market. Without it, I would never have been free of malaria. It is an absolute life saving treatment, extremely fast and efficient, but it wasn't until 2001 that WHO revised its guidance to make coartem a front line treatment. Before that, they still recommended ineffectual quinine-based products in resistant areas.

If a physician went to Burma and prescribed chloroquine, they would be negligent. When UNICEF does the same, it's called 'international aid'. — Amir Attaran

For more on the trials and tribulations of UN aid agencies, check out Emergency Sex: True Stories From a War Zone.

There was so much more in this book on the history of malaria, the winding road to development of drugs, the problems faced by scientists and health professionals in the fight against malaria today. However, I will stop here, as I've already said quite a lot. I highly recommend this book if you're interested in  the subject. It's easy reading and full of anecdotes and interesting information.

I particularly sympathised with one sufferer who was mystified at her sudden craving for ice-cold orange Fanta. For me it was lemon Fanta citron. It is a strange disease, indeed.