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.
Nowhere in Europe was the scourge more deadly, and the need for a cure more acute, than around the Basilica of St Peter’s in the centre of Rome, where every summer for centuries it killed hundreds of people, making no distinction between peasant, priest or pope.
‘When unable to defend herself by the sword,Rome could defend herself by means of the fever.’
GODFREY OF VITERBO, poet, 1167
Giacinto Gigli lived for sixty-five years in an alleyway by the Via delle Botteghe Oscure. His small townhouse was one of several built close together. They clung, like a gaggle of shy children, to the end of one of the crooked passageways that cluttered the centre of Rome, seeming almost to lean into one another when the wind whipped around them during the early days of winter. Gigli was not born there, but from the time when he was twelve years old until just before Christmas 1671, when he died at the age of seventy-seven, he returned every night from his work in the papal palace at the Vatican and climbed the stairs to the study, his favourite room, at the top of the house, where his desk was placed between two tall windows.
One of them looked westwards, over the bend in the Tiber where tradesmen, prelates and visitors would cross the bridge that led towards the Santo Spirito hospital and beyond it to St Peter’s and the palace of the Vatican. From that window Gigli could just see the golden dome of St Peter’s, though often it seemed almost to fade away in the summer haze, when the city