New York Times review of The Fever

Mosquitoes transmit dozens of infections, but none is as complicated or as sinister as malaria. Its very name (from the Italian “bad air”) conjures up the wispy miasmas of a B horror movie. And indeed, this is a disease written in unnerving shades of gray. People can live with it for decades or die from it overnight. Immunity is patchy and incomplete. Drugs work, except when they don’t. Vaccine makers create ever more promising failures. Over the eons malaria has arguably helped kill more people than any other force on earth.

And here is how stories about it usually begin: “Malaria is a mosquito-borne infectious disease caused by a eukaryotic protist of the genus Plasmodium … ” (this particular yawn-maker courtesy of Wikipedia). So Ms. Shah, a Boston-based journalist, has performed a real public service in telling the story of malaria with all the drama, intrigue and human interest left intact.

The little blobs of matter responsible for malaria are so devious they could give lessons to the C.I.A. Plasmodia change shape like a magician’s scarves as they move from a mosquito’s intestine to a mammal’s bloodstream and then back again. Each of the species that cause human disease has its own “shtick,” Ms. Shah’s word, to keep it alive and causing trouble. The most vicious, falciparum, explodes millions of red blood cells at a shot and can kill overnight. Vivax, less dramatic but more persistent, hides in the liver and can keep a person weak and miserable for years.

The mosquito is also a sketchy character: of more than 3,000 species, only 70 members of the genus Anopheles transmit malaria parasites. Each of them has its own finicky habits: some like mucky water, some like clear water, some die in the cold, some hibernate till spring. With each minor change in mosquito behavior comes a different set of options for disease control — but the mosquitoes have a habit of changing their ways to thwart all control.

What a cascade of misery this disease has brought, dogging civilization’s progress like a bad conscience. You build a dam, malaria develops upstream. You dig a canal, your expensive workers (specially imported from nonmalaria zones) drop like flies. You wage a war, and malaria kills more troops than the enemy does.

And yet, sometimes the disease has worked to its victims’ advantage. Julius Caesar may have shivered with fever on his imperial couch in Rome, but malaria in the surrounding regions helped protect his empire from intruders. People lucky enough to survive childhood infections will seldom be bothered much with the disease as adults.

Ms. Shah does a virtuoso job with the frustrating history of antimalarial treatment. Quinine, one of history’s great herbal drugs, potent but toxic, was extracted from tree bark well into the 20th century. Chloroquine, a synthetic derivative, was even more potent and much less toxic — it was the perfect drug, until, in the usual way of infectious diseases in our era, the malaria parasites became resistant.

That cycle has now repeated itself with every good antimalarial drug up to and including the latest, artemisinin. “It will be at least 10 years before a drug that good is discovered,” mourned a World Health Organization official in 2006. “Basically we’re dead.”

Meanwhile, in many undeveloped parts of the world, the disease is just one of those things. Despite the urgency of the newest Gates-Clinton-Bono antimalarial cabal, people often consider it a minor malady, like a cold, and shrug at the West’s obsession with taming it. According to one estimate, only 20 percent of those with malaria actually seek curative treatment, and then only a third of those take the drugs as prescribed. Life-saving insecticide-treated mosquito nets, donated by the West with much fanfare, are sometimes repurposed to catch fish.

Ms. Shah, an American of Indian descent, learned this all firsthand: “Nearly every Indian relative of mine reacted to my writing this book with mild puzzlement, as if I’d announced I was working on a book about bunions.”

The only small problem with Ms. Shah’s narrative is the likelihood that if you don’t know your falciparum from your vivax and your merozoite from your schizont, you won’t be learning it all here. The ridiculously baroque lifecycle of plasmodia are best grasped from straightforward text with lots of diagrams and tables, not poetic language with lots of adjectives.

But the technical details are easily available in a dozen other places. What is available nowhere else is Ms. Shah’s riveting panorama of malaria in 21st century: babies in Malawi dying despite the best available treatment, well-financed Harvard researchers plotting a genomic attack on the disease, activists aiming to rehabilitate the pariah insecticide DDT. And then there is the casual mention of a parasite that used to cause malaria only in monkeys and is now showing up in sick people in Asia.

It is testimony to Ms. Shah’s talents that even as her fluent, intelligent commentary runs on, the reader never stops hearing the ominous soundtrack in the background: Whine-slap. Whine-slap.

From The New York Times, July 27, 2010