Category: The Fever (page 1 of 4)

Bill Gates reviews “The Fever”

Screenshot 2015-01-05 08.54.24My book, The Fever, is not uncritical toward the role the Bill and Melinda Gates Foundation has played in shaping global priorities around malaria. They’re big, they’re aggressive, and as a private entity they’re fundamentally non-democratic. I have a problem with all that, and I’ve written about why in my book and in articles.

So I was pleasantly surprised to see that Mr. Gates recommended my book in his blog GatesNotes, and also picked it as the first of just 4 “good disease books” he’s read in recent years.

If you want to read just one book about malaria, The Fever is probably the best choice. Author Sonia Shah doesn’t overwhelm you with data and analytics, but she does cover the whole history of the disease, which—as the title suggests—goes back further than you might think. The book was published in 2010, so it’s not totally up to date (most notably, we’ve made progress with rolling out bed nets since then). But it’s a great overview of malaria, its impact, and the solutions to it. -Bill Gates

“The Fever” is in extremely good company on Gates’ list. The other 3 “good disease books” are by Bill Foege and D.A. Henderson, leaders of the smallpox eradication campaign, and one of my favorite authors, the physician-anthropologist and founder of Partners in Health Paul Farmer.

On National Geographic Weekend Radio

I’ve had National Geographic magazines sprinkled around my house for years, and several of their amazing photographs are indelibly seared into my brain. So it was an extra fun experience to be interviewed for their weekend radio show, which aired this past Sunday, May 18. Boyd and I chatted about malaria and mosquitoes. You can hear it here.


Revenge of the microbes: taming drug-resistant malaria


An alarming new report published by The Lancet on April 5 reveals that drug-resistant malaria has spontaneously emerged from yet another hotspot in southeast Asia. If the super-parasites erupt elsewhere—such as in malaria’s African heartland—years of progress against the disease could be rapidly unravelled.

Malaria parasites that resist the wonder drug, artemisinin, were first sighted five years ago, in western Cambodia. Alarmed public health officials sprang into action, with stepped up containment efforts to prevent the bug from spreading. But all that may have been for naught, as a team of international researchers now report that similarly impervious malaria parasites had already emerged along the Thai-Myanmar border, some 800 kilometers away. Evidence suggests that they did not spread there from Cambodia but rather arose spontaneously, eight or more years ago.

Containment, in other words, is no longer possible. For the millions whose lives have been saved by artemisinin drugs, this is worrying news indeed. It’s possible that these impervious parasites could erupt almost anywhere artemisinin drugs are used. Perhaps they already have.

Ironically, artemisinin drugs saved the world from an earlier drug-resistant malaria. Launched after World War II, chloroquine was for decades the world’s wonder drug for malaria, popped like aspirin across the tropics. Widely available for pennies without a prescription, people consumed it with abandon. Chloroquine-resistant malaria first emerged in 1957, and within a few decades had spread from Southeast Asia across the globe. With no drug in sight to take its place, malaria deaths skyrocketed, tripling over the course of the 1980s and 1990s.

Artemisinin drugs capable of taming chloroquine-resistant malaria became widely available only after 2004, when international donors and the World Health Organization started to promote their distribution. International drug programs such as the Affordable Medicines Facility for Malaria, the brain child of the Nobel-prize-winning economist Kenneth Arrow, aimed to blanket the malarious world with artemisinin drugs, providing massive subsidies so that these meds—like chloroquine—would become widely available, without a prescription, for pennies. It worked. By 2010, global production of artemisinin drugs had increased to 130.6 million doses, from just 11.2 million in 2005. The distribution of these drugs coincided with scaled-up prevention efforts, in which insecticides were impregnated into hundreds of millions of bednets and sprayed on the interior walls of scores of homes, to kill and repel malarial mosquitoes.

Now the gains of that chemical blitz—a 31 percent drop in global malaria mortality between 2005 and 2010— are under siege. Along with drug-resistant parasites erupting in southeast Asia, malarial mosquitoes resistant to antimalarial insecticides have spread across central and western Africa.

Elsewhere, other infectious diseases are similarly routing our killing chemicals. In recent years, bacteria capable of defanging our most powerful antibiotic drugs have emerged and spread, such as the notorious NDM-1 or “New Delhi metallo-beta-lactamase 1,” which can resist 14 kinds of antibiotics, including the last-resort drugs used solely in hospitals, and which has so far spread to over 35 countries. Extensively drug-resistant, or “XDR” tuberculosis, plagues at least 58 countries, and in January, India became the third country after Iran and Italy to fall victim to totally drug resistant or “TDR” tuberculosis, an untreatable form of the disease.

Call it the revenge of the microbes. The more poison we throw at them, the faster they learn to circumvent our chemicals. That reality is also why the tools required to continue fighting this war are becoming increasingly scarce. Experts expect it will be at least 8 years before a new drug to treat drug-resistant malaria makes it to market. There hasn’t been a new drug launched to treat tuberculosis in nearly 50 years. There are currently no drugs in development that will treat NDM-1 bacterial infections. Why? Because these drugs are expensive to develop, and yet, the more people buy them, the faster the drug becomes obsolete and un-sellable. As a result, very few drug companies spend much time or money developing anti-microbial drugs anymore. It’s bad for business.

The sad truth is that each wonder drug we’ve thrown at malaria—and every other infectious disease—has fallen to drug-resistant pathogens. Artemisinin drugs, it seems, may be next. But the next generation of wonder drugs doesn’t have to suffer the same fate.

Microbiologists and others are developing new approaches to drugs and insecticides that minimize the emergence of drug-resistance, by targeting only the worst, most disease-causing aspects of pathogens. In malaria, for example, Penn State biologist Andrew Read has proposed the development of insecticides that leave intact young, reproducing mosquitoes and target only the oldest mosquitoes that are most likely to transmit malaria. That way, insecticide-resistant mosquitoes have zero advantage over susceptible ones. Insecticides and drugs developed using this logic could be virtually “evolution proof.”

Similarly, scientists are developing new rapid diagnostic tests that can ensure that bug-fighting drugs are used exclusively on active, disease-causing infections, greatly reducing opportunities for drug-resistant bugs to spread. New drug-resistance surveillance networks can now use molecular techniques to pinpoint the earliest signs of resistance, so that drug regimens can be changed before they fail. Disease-prevention methods that don’t rely on killing chemicals at all, such as improved housing and environmental management for malaria, and better hospital hygiene in hospitals and communities for drug-resistant bacteria, can help ward off infection without encouraging drug-resistant microbes at all.

Slowing the spread of drug-resistant malaria will take time and resources. But it’s better than the alternative: the loss of yet another wonder drug and a new era of unstoppable infections.

Are treated bednets failing?

are treated bednets failing?

are treated bednets failing?

The LLIN—“long lasting insecticide treated net”—is actually not very long lasting, after all. Years ago when I first started learning about them, I was told by experts that they were meant to last 3-5 years. That’s longer than older model nets, but for a disease as pernicious as malaria it is really not particularly long at all. Many of the most avid net distributors and fundraisers have tended to sideline this rather salient fact. Well, now good evidence has emerged that these nets indeed last for three years—and three years only—throwing into question the very idea that “nets save lives.” Perhaps the mantra should be “nets delay malaria for a few years.”

Between January 2007 and July 2008, the incidence of malaria among the people of Dielmo, Senegal ran to around 5.45 per 100 person-months. This village has been studied by the Pasteur Institute since 1990, when they started systematically testing the blood of people with fever for malaria parasites. People there get about 258 bites from infected mosquitoes every year. In 2008, LLINs were distributed, and incidence dropped dramatically, to just .41 per 100 person-months.

Two and a half years passed.

And then the nets stopped working.

Malaria spiked back up to 4.57 per 100 person-months, nearly the same level as it was before the nets were distributed. And all those little kids who’d been sleeping under them—now a bit older—started getting sick with malaria.

Generally, malaria cases in endemic areas are concentrated in pregnant women and children under five years old. Older children and adults, having acquired some immunity to the malaria parasite, generally don’t get as sick, and few die of malaria. Except in Dielmo, where researchers were actively surveilling the population, testing people with fevers for malaria. There, most of the rebound in cases in 2010 occurred in adults and children who were 10 years old or older, suggesting that these individuals had been stripped of their acquired immunity during the years when the nets protected them from exposure to malaria.

Indeed, when the researchers analyzed local Anopheles gambiae mosquitoes, they found the telltale kdr mutation, which confers resistance to pyrethroid insecticides, of the kind used in nets. The frequency of that gene in the local mosquitoes increased from just 8 percent in 2007 to 48 percent in 2010. (The nets were samples and checked for insecticidal activity and holes and the like and were found to be intact.)

So, was anyone’s life saved? What was the (ahem) net effect of all those nets?

For more, see: Jean-Francois Trape et al., “Malaria morbidity and pyrethroid resistance after the introduction of insecticide-treated bednets and artemisinin-based combination therapies: a longitudinal study,” The Lancet Infectious Diseases, In Press, Corrected Proof, Available online 17 August 2011, ISSN 1473-3099, DOI: 10.1016/S1473-3099(11)70194-3.

Is history repeating itself?

Anyone familiar with the history of malaria control will find the below article, from NatureNews, unsettlingly familiar. Western donors  flood the malarious world with insecticide-treated bednets, and foresee malaria’s impending demise. Experts warn that the mosquitoes will learn to rout the chemical blitz; supporting evidence piles up, and is ignored; the years go by. Then, just as financing for the chemical blitz becomes shaky, we hear official recognition of the increasing weakness of anti-malarial insecticides. Now, more money will be needed to develop alternative insecticides, or use combinations of insecticides, but of course there is less money to go around, and many millions of nets treated with the old, increasingly ineffective insecticides hang in huts across Africa. Who will replace them? And with what? And how?

See “Mosquitoes score in chemical war: Growing resistance is threatening global malaria-control efforts,” NatureNews, July 5, 2011.

And check out a very similar story, from 1952, which presaged the collapse of the DDT blitz against malaria, and its subsequent resurgence in the 1980s and 1990s: “Mosquitoes developing an armor against DDT after 9-year-war,” New York Times, March 14, 1952. (For more, see my chapter on “The spraygun war” in The Fever.)

"The Fever" long-listed for Royal Society Winton Prize

So honored and flattered to find out that “The Fever” is one of 13 science books long-listed for the Royal Society Winton prize, considered the Booker Prize of science writing. The short-list of 6 will be announced in September, and the winner in November. Fingers crossed!

Helen Epstein's thoughtful review/essay on "The Fever" in this month's Harper's


AIDS journalist Helen Epstein takes on malaria politics in this month’s Harper‘s magazine, in a long and thoughtful review essay on The Fever. It’s enough to make a gal re-subscribe (which I just did!)

Picador's paperback edition of 'The Fever" this June


Coming this June, Picador’s paperback edition of ‘The Fever,’ complete with spiffy new cover. Keep an eye out!

George Clooney taking questions about malaria at

Yes, another famous person has come down with malaria! It was British model Cheryl Cole most recently, and now the actor George Clooney, who has just recovered from a bout contracted in Sudan. He’s taking questions about the disease at, via Nicholas Kristof’s blog.

It’ll be interesting to learn whether he took prophylaxis or not. I suspect he did not. Many Westerners who  travel regularly to malaria-endemic regions don’t, including some top malariologists I’ve met. I suppose they feel immune, sleeping in air-conditioned rooms and enjoying easy access to prompt treatment. And mostly they are, compared to the 300,000+ people living in huts and slums who get infected every year. Personally, though, I’d never skip the preventive drugs. The history of malaria shows that that wily parasite and the mosquito that ferries it around are full of secrets and surprises.

On a separate note–I once appeared in a documentary about the film “Syriana,” talking about oil politics in connection with my book “Crude.” As George Clooney stars in “Syriana,” he appeared in the documentary too. Which means, of course, that I was in a movie with George Clooney!

Wall Street Journal on "The Fever," and "The Imaginations of Unreasonable Men"

“The lessons of history should give us pause,” writes the medical historian W.F. Bynum in a long piece about malaria vaccines in Friday’s Wall Street Journal.

The occasion for Bynum’s piece is the publication of an optimistic new book about malaria vaccines, written by the entrepreneur-philanthropist Bill Shore, with the somewhat nauseating title of “The
Imaginations of Unreasonable Men: Inspiration, Vision, and Purpose in the Quest to End Malaria.” (I’m no strident stickler for gender-neutral language, but really? Unreasonable men? In the TITLE? Take that, Melinda Gates and Regina Rabinovich.)

Shore’s book is an homage to the charitable work of Bill and Melinda Gates, giving “upbeat profiles” of Gates Foundation beneficiaries, as Bynum puts it. Bynum tackles the question as to whether their quest to develop a malaria vaccine is really the be-all end-all of malaria. “Most malariologists agree that malaria cannot be eliminated without a vaccine,” he writes. “But that does not mean that a vaccine will necessarily eliminate malaria.” Quite.

It’s a great piece. (And not only for this: “All these issues, and many others, are brilliantly exposed in Ms. Shah’s book.”)

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