The Miraculous Fever-Tree: Malaria, Medicine and the Cure that Changed the World

Back in Kenya in the early 1950s he had a third bad attack, and in 1958 a fourth while on a long winter visit to Europe. After that, it would often strike when the rainy season was under way. Our farm, with its warm climate and its clumps of thick papyrus that stretched out for yards into Lake Naivasha, was the perfect habitat for the Anopheles mosquito that spreads the disease. In the rainy season, when the mosquito larvae hatch in their thousands, it can be especially bad, and even today we always sleep under mosquito nets.

I have had malaria only once, when I was eighteen. I had been on holiday at the mosquito-ridden Kenyan coast, and cared little about remembering my pills. That was enough. Soon after I returned, I began feeling unwell. I took my temperature. 101°F. By nightfall it was up to 104° and I was beginning to hallucinate. With any other illness, I have always felt that I was still myself. I might be in pain or feel nauseous, but I was me – only sicker. Sick with malaria, however, my body felt it was no longer my own. It had been invaded, as if it had been subjected to a military coup. I remember walking into my father’s bedroom; I watched myself, as if I were another person completely. The fever was just beginning to shoot up. The parasites in my blood that had invaded the red corpuscles were splitting them open and destroying them in a rampant urge to reproduce. I lay down on the bed, and passed out. After that everything is blank. My blood had been hijacked. That is how the delirium begins. ‘I have lain on my cot for forty days,’ the explorer David Livingstone wrote to his wife from Luanda, in present-day Angola, in 1854. ‘So fierce was the delirium that I remember almost nothing of it.’ The fever would kill him nearly twenty years later. Clearly, I was lucky.

My father gets it more often than any of us, and worse. Just a few days before I wrote this, he called to say he was ill again. ‘I began to feel colder and colder and colder,’ he told me, his voice thin with fever. ‘I got into bed with a hot water bottle and kept piling on blankets. For two or three hours I just shivered and shuddered as if I was in an icy blast. Then, suddenly, it stopped. And I started getting hotter and hotter and hotter, and throwing all my covers off. Forty-eight hours later it started all over again. And every forty-eight hours it’s been the same for about a week.’

As always, my father went to his Italian doctor in Nairobi, Mauro Saio, one of the world’s leading specialists in treating malaria. Dr Saio has worked so long with the disease that he named his speedboat Anopheles after the mosquito that spreads the disease. ‘You have headache, vomiting, diarrhoea,’ he explained, ‘and if it’s not caught in time and the parasites keep reproducing, you can have respiratory distress and systemic organ failure.’

For Dr Saio, combatting malaria is a campaign. As he told me the first time we met, ‘It’s a battle. A hard battle. I know this disease. I fight this disease every day of my life. It is my personal enemy.’

My grandparents tried to protect themselves and us, my sister and my four cousins. As far back as I can remember, the daily ritual of breakfast on the farm was broken on Sundays by the distribution of the quinine, or its modern chloroquine-based equivalent, Nivaquine: two tablets for the grown-ups, and for the children a spoonful of Nivaquine syrup, which was increased to two spoonfuls when we were about twelve years old. Oh, it tasted awful. It wasn’t like today, when pharmaceutical companies try to make their medicines palatable to children; in the 1960s they had other priorities—all a medicine was required to do was to work, and you just had to take it. Quinine is marked by its particularly bitter taste. Over the centuries, many people have refused to swallow it for fear that they were being poisoned.

Nivaquine is also bitter, and the vile taste of the syrup clings to your teeth and gums long after you have swallowed it down. Just writing about it makes me wince at the memory. It tasted so ghastly that my grandfather had to devise his own method for persuading us children to take it. He bribed us. If we swallowed down the Nivaquine, we were allowed to choose what we would have for Sunday lunch.

This was no mean bribe, for my grandfather was a tremendous cook. By his place at the head of the table lay a book covered in well-loved, shiny dark red leather. Il Talismano della Felicità was written nearly a hundred years ago, and it contains instructions for making every manner of Neapolitan delicacy. Once we had all swallowed our Nivaquine, my grandfather would pour himself another cup of black coffee, drop into it a lump of sugar, light a cigarette and then reach for his Talismano. Slowly he would turn the pages, stretching out the agony of anticipation. And then he would begin, in a deep, sonorous voice. ‘So, bambine, what will it be today? Pizze fritte? Sartù di riso? Maccheroni al ragù? Melanzane alla parmigiana?’ We would vie to be the one who made the final choice, completely forgetting the filthy taste of the Nivaquine in our anticipation of the meal to come. In our house, the danger of malaria was vanquished by greed.

When I was fourteen, I was sent to boarding school in England. I arrived at my new convent school in Sussex on a bleak January afternoon. Snow-filled clouds hung over the landscape like a laundry bag waiting to burst. One of the Irish nuns showed me into a dormitory with seven beds covered with old rose-coloured candlewick bedspreads. Her manner was brisk, and she didn’t stay long. I had arrived in the middle of the day in the middle of the school year, and she had things to be getting on with. The other girls were in class, and every bed in the dormitory had been taken except one, that stood alone in the middle of the floor. Slowly I unpacked my trunk, and stowed away the clothes my aunt had ordered off a long list from a department store in central London: thick white underpants (inner, changed daily), huge navy-blue serge underpants (outer, changed weekly). I thought of running barefoot in the soft African dust and splashing in the ditches by the side of the farm roads, and felt a bit sick with the longing to be back home. None of my roommates, it turned out, had ever been to Africa. They giggled among themselves and argued endlessly about the merits of rival pop stars. At night, they tossed and mumbled and farted in their sleep. There was not a moment of privacy. We even had to share baths. By the end of term the seven of us had been living so closely together for so long that our menstrual periods all began and ended on the same day. But that did not bring us closer. The loneliness of living in a foreign crowd so far from home was with me always. I felt that I had landed on another planet. There was something about the fact that my family, my entire tribe, had packed up everything it owned and turned its back on Europe that set me apart. It was as if I had lived my entire life in another language.

As the winter wore on through February and the windy weeks of March, I felt as if it would never end. I missed my sisters and the mental shorthand we assumed together because we had always lived in the same house. I missed the tropical rituals: barbecues at Christmas, snow that came in tins for spraying on the Christmas tree, and the way the sun went down every day at the same hour, whatever the season. I even missed the beastly Nivaquine, for the danger that forced us to take it was something familiar to me. I missed my grandfather’s sweet tomato sauce, and the smell of the land after it had rained. I missed everything so much that I would lie awake at night trying to conjure up the smells of home. It was as hard as sewing raindrops.

Then one day, on one of the rare weekends we were allowed out, a friend of my father’s took me on a long Tube journey to St Joseph’s Foreign Missionary Society in Mill Hill, in the very outer suburbs of north London, where he had to pick up a package. St Joseph’s was the male equivalent of the convent school I attended. But while my Irish nuns had devised a whole book of rules for keeping us from talking to boys or fraternising in any way with the outside world, St Joseph’s positively encouraged a spirit of independence in its young men.

During the time that my father’s friend concluded his business, I wandered down a long corridor, the walls of which were covered in small photographs of all the priests who had ever served St Joseph’s abroad. The early ones were sepiatinted. Gradually they became black-and-white. It was there that I realised for the first time that pulling up your roots and embarking on a new beginning was something people had always done. Though they knew they might never return, like my grandparents those priests had rolled the dice and boarded ship.

St Joseph’s Foreign Missionary Society, or the Mill Hill Fathers as they are commonly known, now has missions in nineteen different countries, stretching from Brazil to St Helena and from Brunei to Sudan, which is impressive in our secular age.

At the end of the corridor was a large wooden door which led to the Society’s chapel. On a stand to the left of the altar I found a red leather-bound Roman missal. It was open at the page of prayers for persecuted Christians: ‘Father, in your mysterious providence, your Church must share in the sufferings of Christ your son, give the spirit of patience and love to those who are remembered for their faith in You, that they may always be true and faithful witnesses to your promise of eternal life.’

Faith was what had inspired the Mill Hill Fathers to go across the seas. Yet when I sat in the pew of their little chapel and looked around the walls, I realised that it was not a weakening of belief, nor persecution, that killed their priests so often and so young – but disease: overwhelmingly malaria. Running along the top of the wall, just under the eaves, was a stone course carved with the words: ‘Pray for the Souls of our Dear Brethren, the Diseased Missionaries of St Joseph’s Society.’ Beneath it, covering all four walls, were stone slabs listing the names of the hundreds of missionaries who had died in the course of doing God’s work. The first slab covered 1872 to 1905, the years of the Society’s earliest ventures abroad. On it were the names of thirty-two men, starting with the Reverend Cornelius Dowling, a doctor as well as a priest, who died of malaria in Baltimore on 9 August 1872, at the age of thirty-one.

Like the Reverend Dowling, two-thirds of those commemorated in the chapel had died before they reached the age of forty. They succumbed, far from home, in India, Kashmir, Borneo, Italy, France, Uganda and Singapore. As the years progressed, the ever-expanding array of places where the Mill Hill Fathers passed away is proof that sickness and death did nothing to quench their Christian fire. By 1917 the missionaries were dying in the Congo, Borneo, Uganda, the Philippines, the Punjab and on the Isle of Wight. By 1925 it was Sarawak, Madras, Kisumu in western Kenya, and in the dry north of the country, the bleak and lonely Kavirondo Gulf. The dangers they faced were multiple, yet according to the records, fully three-quarters of them died of the same thing: Roman or intermittent fever, tertian ague, or as it later came to be known, malaria.

It took a special kind of courage to leave home and travel to Africa in the nineteenth and early twentieth centuries. Not only were the distances enormous and the prospects of return uncertain, but Europeans thought of Africa as a kind of wild and unpredictable beast that had to be beaten into submission physically, morally and politically.

There were dangerous animals, savage tribesmen and, always, the threat of disease: sleeping sickness, river blindness, yaws, leprosy, trachoma, typhoid, tick fever, filariasis, beriberi, bilharzia, kwashiorkor, rinderpest and East Coast Fever were just a few of the ailments waiting in Africa. Of the many illnesses threatening both man and beast, though, none seems to have preyed on travellers’ minds as much as that which became known in many parts as the ‘pioneer shakes’ – malaria.

Some diseases were terrifying simply because they were deadly. Yellow fever and malaria’s cousin, blackwater fever, which turns your urine the colour of dark Burgundy and your kidneys into fragile sacs that can burst at the slightest movement, are like poisonous snakes: they kill in a matter of hours. But there is something particularly insidious about the way malaria stalks its victims, the way its parasites lurk within the body, hiding from its immune system and lying silent for years until you think you have finally shaken it off, only to find that it always returns, driving you mad with fever, shivering, delirium and pain, weakening you more with every bout before, often, it eventually kills you. As the malaria parasite reproduces in your blood, it swells and bursts out of your red blood cells, leaving in its wake a sludge of wrecked haemoglobin. Some of this material ends up in the liver and the spleen, causing them to swell and turn black. In the unlucky few the parasite accumulates in the capillaries of the brain, causing the cerebral malaria that kills so fast.

Of the thirty-six girls in my primary school class in Kenya, eleven were dead before the age of forty. Five were killed in car accidents, most of them by hit-and-run taxi drivers, who are paid by the journey and drive as fast as they can. One died in childbirth. But four died of cerebral malaria, caused by the deadly Plasmodium falciparum parasite, which kills so many people in Africa. Perhaps, as I had done when I was eighteen, they had become cavalier about the dangers, and didn’t take their anti-malaria tablets; perhaps they were just unlucky, and failed to get adequate medical treatment in time. Between them they left nine orphaned children.

Daily life in Africa is so harsh that there is often little time to dwell on the nuances and inequities of history. Uppermost in the minds of Europeans who travelled there, from the earliest years, was how to overcome disease before it overcame you. Many who live there today still think of malaria as a ghostly presence in their lives; something that visits and revisits with the advent of the rainy season, and from which you never quite escape. In the nineteenth century Henry Morton Stanley, who reckoned he caught malaria more than two hundred times during his exploring years, carried his own cure, which he called a ‘Zambesi Rouser’, made of powdered jalop, calomel, crushed rhubarb and quinine, ‘to be taken with a little water whenever an attack of malaria threatens’. My father is more circumspect. He takes his weekly pills in silence, and only ever talks of having a ‘touch’ of malaria, or even a ‘go’ of it, as if loudly to invoke a more severe diagnosis might in some way be calling down the fury of the fates.

Fourteen miles from my grandparents’ farm, on the other side of Lake Naivasha, is the small district hospital. Thirty beds are divided between three wards, but in the rainy season, when malaria can reach epidemic proportions, patients have to queue up to be admitted. Even in the dry months a steady stream of people, most of them women with small children, line up at what passes for an outpatients department round the side of the hospital. Most of them will have travelled in a hot bus or walked many miles to get there, and they sit, uncomplaining and undemanding, beneath the sprawling pepper trees while they wait, sometimes for hours, to be seen by a doctor.

‘No wonder they’re called patients,’ laughs a nurse holding a blood sample. She appears cheerier than she ought to be, considering the long hours of work that still lie before her. She and three doctors will see about 180 patients in a morning, spending enough time with each to give a quick diagnosis, offer a prescription or decide if further examination is needed. There is none of the smart whiteness of Dr Saio’s office at the main hospital in Nairobi, though the work that is done here is very similar.

The hospital in Naivasha is run by local community doctors. The consultation rooms are spotless and the walls are papered with educational posters about AIDS, safe sex and the importance of using clean water for mixing infant formula. Everyone pays fifty US cents to see the doctor, the same again for a blood test, and between ten cents and a dollar for medicine. A limited range of drugs is supplied cheaply by the Anglican Church which, despite its charity, is Protestant enough to have concluded early on that people value something more if they have to pay for it, no matter how small the sum.

Outside the door is a hand-painted sign with a message from the first Book of Peter, a reminder that so much in Africa is still a matter of faith. ‘Cast all your cares unto Him, for He cares for you,’ it says. Cheap and simple to run, the clinic is more effective than one might think, given its simple furnishings and tiny annual budget. For many Africans, this is the very best medical knowledge they will encounter.

A woman in a red patterned skirt and a white headscarf enters the consulting room. Asked what her name is, she mumbles ‘Grace’ in a barely audible voice. She complains of a swollen stomach. A nurse palpates her abdomen, and concludes that she is about twenty weeks pregnant. Although this would be her third child, Grace seems not to have noticed that her menstrual periods had stopped, or had any idea that she might be expecting. Perhaps another child was too much of a burden for a poor family, and she did not want to admit the truth. The nurse signs her up for admission to the hospital five months hence, and arranges, meanwhile, for fortnightly antenatal visits.

The next patient, Joseph, complains of chest pains. He has chronic oedema. His lower legs look like tree trunks and he suffers from high blood pressure. He pulls his thick jacket around him as the doctor prescribes a new medication for his angina, and shuffles out.

A heavyset young woman in red flipflops and a blue headscarf comes in next. She speaks softly to the doctor in Kikuyu. She is called Sandra. Both her children are running a temperature and she has a bad chesty cough. She wants them all to be tested for malaria. The doctor examines them. ‘Say “ah”,’ he commands, peering down the throat of each child.

The thick white ulcers of oral Candida indicate that they are probably both HIV positive. Without proper medication, it will only be a matter of time before they have AIDS. On the wall is a poster of a strip cartoon showing how AIDS is transmitted. It says nothing about foetal transfer of the virus. Beside it another chart outlines how to prescribe Amodiaquin, the standard treatment for malaria now that chloroquine, a synthetic anti-malarial compound developed during the Second World War, is so ineffective that many African countries, including Kenya, have discarded it. For a baby of less than seven kilos, you give a quarter of the daily dose. For a child weighing more than fifty kilos, the daily dose is three tablets.

The nurse asks each child to put out a hand. Gently she swabs a finger, pricks it and smears the gentle swell of blood onto a glass slide. Moments later a lab technician dips the slides into staining fluid, dabs the end with a piece of kitchen towel to clear the excess moisture, and puts the slide to dry on the warm back of a paraffin picnic fridge beside his desk. In a few moments the slides are ready and he slips them under the microscope, the only piece of machinery in the clinic that runs on electricity.

The circular-shaped parasite, with its dot-like red eye at one edge that is so characteristic of malaria, is clearly visible. Sandra and her two children all have malaria, though they are lucky they do not harbour the deadly falciparum parasite. A pharmacist counts out a tiny handful of white pills and slips them into a small square envelope. They are quinine sulphate, which is made from the bark of the cinchona tree grown in the last cinchona forest, in the eastern Congo.

My grandparents may have been unusually adventurous in the way they happily traded in a comfortable life in Paris for an unknown future in Africa, but their caution in insisting that we all regularly dosed ourselves with quinine was proved right. To many Western travellers today, malaria is something that exists over the horizon. It does not carry the slow promise of death that is embedded in AIDS; in this part of Africa, AIDS has seeped into so many villages that small children and old grandparents are often the only people still to inhabit the silent thatched huts. Nor does malaria conjure up an explosive, primitive fear, like being attacked by a lion or bitten by a poisonous snake. Most travellers know that malaria exists, but they buy an ordinary over-the-counter dose of prophylactics and go on holiday regardless, often ignorant of whether the prophylactics work or not. In Britain there are more articles in medical journals devoted to the depressive side effects of mefloquine, or Larium as it is usually known, one of the strongest anti-malarial prophylactic drugs on the market, than on the disease itself.

Malaria stalks Africa, where it is a real cause of fear and grief. The United Nations World Health Organisation estimates that as many as five hundred million people are infected by the disease every year. That is eight times the population of France or Great Britain, or twice as many people as live in the United States.

Of those who fall sick, as many as three million die every year. The very large majority of these are small children for whom clean water, decent food, antibiotics and quinine-based drugs to fight the onset of the disease, let alone a decent prophylactic, are no more than a dream, perhaps heard of, but unattainable. Malaria is so common, and so deadly, that the WHO estimates one person dies of it every fifteen seconds. In the last decade it has killed at least ten times as many children as have died in all the wars that have been fought over the same period. Yet the mosquito that carries it is little larger than an eyelash.

Out of just under five hundred different varieties of Anopheles mosquito that are recognised today, only about twenty are thought to be seriously responsible for spreading the disease to humans. The malaria parasite packs the salivary gland of the female mosquito, of no danger to anyone including its host until it bites a human being. Only when it injects some of its saliva containing the malaria parasite into the bloodstream does the mosquito transfer this dread disease. In the course of the bite it also withdraws blood. Its victim may already be infected with the parasite. If the mosquito moves on to other people and bites them, the endless cycle of infection and reinfection will simply repeat itself. The Anopheles mosquito needs blood to lay its eggs, but the damage it inflicts on humans is completely incidental to the insect. ‘A man thinks he’s quite something,’ the American writer and cartoonist Don Marquis had his cockroach hero Archy say in archy and mehitabel. ‘But to a mosquito a man is only a meal.’

The mosquito breeds in pools of stagnant water – overflows from rivers that have flash-flooded and then subsided, roadside ditches, forgotten furrows in uncultivated fields, water butts in towns and rain-filled puddles in the middle of country roads. In the Naples of my grandfather’s youth, the mosquito found a comfortable home in the well-watered window boxes of the city tenement buildings. When my great-grandfather was in Panama, it was customary for the nurses in the little French clinic on the hill above the engineering works to stand the hospital beds in huge flat bowls of water to stop the black spiders from climbing up the bed legs and biting the patients. No one could have devised a better breeding ground for mosquitoes had they tried. Among the canal workers of the mid-nineteenth century it was customary to warn newcomers that if you didn’t have malaria when you went into hospital, you would undoubtedly catch it while you were there.

Today malaria is chiefly a danger to people in the tropics, particularly the poor, who live in bad housing with inadequate drainage and no mosquito nets, insecticide sprays or fancy prophylactics. But once upon a time it was common all over Europe. Even so, no one knew exactly what it was. Nor did they know how to treat it. When a cure finally was discovered, it revolutionised theories of medicine and the way physicians thought about treating illness.