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Column: Malaria in Shakespeare’s land

June 12, 2014 - 20:01 -- Bart G.J. Knols
“A long time ago, in a galaxy far, far away....”. Although actually this is one of the most famous introductions of the history of movies (and I am pretty sure that most of my readers have recognized it), this is also, in many senses, the way many health professionals think about malaria. Many western doctors and nurses see paludism (malaria) as a remote and tropical disease, even covered with a flavour of romanticism. The truth is that malaria has been prevalent in areas as far north as the city of Groningen (at 53º North) in Holland and has been active until the last decades of the 20th Century in countries as, among many others, The Netherlands, Spain or Australia. In some instances, as Spain or Italy, malaria was not completely eradicated until the 50s or 60s. For example, a breakout of indigenous cases of malaria was confirmed as late as 1972 in Corsica, the French Island of the Mediterranean Sea.

It can be even a little shocking but even the United Kingdom, with its never-ending green prairies and its cloudy and cold weather, had once some endemic malaria areas. Although we can trace signs of malaria in the main British Island until the roman domination, it was especially during the seventh and eighteenth century when in certain areas of England (mainly the Fens, the Thames and the coastal marshes of the southeast) malaria was very prevalent. In Britain, there are several endemic species of Anopheles mosquitoes that can transmit Plasmodium, but only An. atroparvus has a population big enough to interact with humans and act as a malaria vector. Regarding the parasite, P. vivax and P. malariae are the most prevalent. But even dealing with the lesser aggressive species of Plasmodium, malaria struck very fiercely those endemic areas mentioned above. Historical studies show us that in these malaria localities, mortality could be double or even triple that of the surrounding villages far enough from the marshes. We can read letters of vicars and other officers refusing to live in those places and even accounts where inhabitants of those areas were described as “'stupid, apathetic and fatalistic”. This, besides the obvious interest in order to study the history of malaria in the past, gives us a very appealing subject of reflection; laziness and lack of initiative in certain populations are product, in some instances, of endemic debilitating diseases rather than social or cultural aspects. 
At the end of the 18th century malaria was almost eradicated from those areas. The increased availability of quinine (the fascinating history of the introduction of quinine in England by Robert Talbor, a London physician and pharmacist who saved thousands of lives can be accounted as one of the first cases of corporate espionage of the pharmaceutical industry. Talbor took some “Jesuit Powder”, as the quinine was known at that time and delivered it as his own creation), the drainage of extensive areas of marshlands and swamps, the general improvement of living conditions…these and probably some other reasons collectively wiped out malaria from England. Later, malaria history in the UK got an epilogue at the dawn of the 20th Century. A group of soldiers, infected with malaria in Greece and India, were transferred to Kent, an area surrounded by marshes. The Anopheles breeding in this area could spread the disease and more than 500 indigenous cases were detected. 
Yes, even in places as “untropical” as the United Kingdom there was a time when malaria was one of the main causes of morbidity and mortality. And Yes, here we have another example of victory against it.
In the next column we will travel from the South, to review the evolution of malaria in Spain and Italy, to the North, to discover a time where malaria was present even in the marshes around the North Sea Basin. 
I hope these reflections make us more familiar with that “tropical” disease that in the past was so close to our ancestors and their lives. Indeed, malaria is also a part of OUR history.

Alvaro Pemartin (Spain) Prehospital Emergency and Remote Site Doctor. My daily tasks are providing emergency and primary care in Remote Sites (Sierra Leone, Guinea-Conakry, Mauritania) Volunteer in my local Civil Protection Agency, Interested in Emergency and Disaster Management and in scientific ways of improving this management (Lessons Learned, Operational Research, Simulation, Modelling)…  Member of International Association of Emergency Managers and Member of the Editorial Board of Crisis Response Journal.



Jeff Juel's picture
Submitted by Jeff Juel on

As a civil engineer, I note in the above column that: 1) the coastal areas of England were particularly afflicted with malaria ; and 2) malaria was prevalent during the "seventh (or seventeenth?) and eighteenth century".

It would be interesting to know what the state of repair/disrepair of the coastal diking and drainage infrastructure (including tide gates) was in those centuries compared to eras when malaria was less of a problem.

I appreciate the importance of feedback loops: Poorly maintained drainage infrastructure produces flooding and stagnant water; stagnant water breeds mosquitoes; which transmit malaria; which results in "laziness and lack of initiative" in the community. Laziness and lack of initiative results in delayed maintenance of the flood control and drainage infrastructure. This completes the feedback loop.

Diking and drainage infrastructure including tide gates (the French Acadians called them "aboiteau") were instrumental in the French colony (Port Royal founded 1605) in Newfoundland during the 17th century. This technology was likely used in the coastal marshes of England prior to and during the 17th century as well. (Being capable engineers, the Romans certainly employed tide gates at various times and places - possibly including the tidal marshes of England in the first century AD.)

In 2014, the American Society of Civil Engineers produced a Report Card for America's Infrastructure. Levee were given a D minus - the lowest grade given. Sea levels are rising, marshes and wetlands are being preserved (rather than filled and drained), and our flood control infrastructure is not being repaired and maintained.

Given this state of affairs, immigration of people infected with Plasmodium and a population of suitable vectors could/will inevitably result in the reintroduction of malaria in the U.S.

The notion that Climate Change (warming) will result in the spread of malaria has been effectively discredited. On the other hand, I know that new coastal flood control projects are not Politically Correct and existing projects are not being seriously maintained.

The projected magnitude of future sea level rise is grossly exaggerated for political purposes. If coastal levees are constructed or refurbished, how high should they be constructed? Should we assume 1 foot of sea level rise per century, or 4 feet? Or 200+ feet - the worst-case scenario for global ice melt due to climate change? (reference the cover of National Geographic - September 2013)

Presuming one foot of sea level rise per century - the anti-climatic rate of rise during the 20th century - would be like shouting "The emperor (Al Gore) has no clothes!". Making levees higher than needed costs money and the levee footprint will cover more wetlands. Four feet of additional height makes the base of a levee at least 16 feet wider.

This impasse could be the real inconvenient truth: Al Gore's "science" and the resulting hysteria are causing an inability to do proper engineering of coastal flood control and drainage. This is a real cause for concern.

Proper & innovative engineering (and science unshackled from politics) will allow sensible flood control and drainage infrastructure. This can be done in a way that preserves and enhances wetlands without producing stagnant water.

Flood control and drainage infrastructure saves lives, reduces property damage, allows agriculture to flourish, reduces the incidence of water-borne diseases, and is important for larval source management.

Please excuse the long comment, but the importance of this should be obvious to anyone concerned with malaria.

Jeff Juel, PE

Submitted by David Warhurst on

In the 2nd world war era, locally transmitted vivax malaria was a problem even past the arctic circle, and certainly in Norway and Finland. The north dutch endemicity is mentioned by the comment.