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Malaria
JULY 2007
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Malaria
By Michael Finkel
Photographs by John Stanmeyer

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To witness the full force of malaria's stranglehold on Zambia, it's essential to leave the capital city, Lusaka. Drive north, across the verdant plains, past the banana plantations and the copper mines—copper is Zambia's primary export—and into the forested region tucked between the borders of Angola and the Democratic Republic of the Congo. This is the North-Western Province. It is almost entirely rural; many villages can be reached only by thin footpaths worn into the beet-red soil. A nationwide health survey in 2005 concluded that for every thousand children under age five living in the North-Western Province, there were 1,353 cases of malaria. An annual rate of more than 100 percent seems impossible, a typo. It is not. What it means is that many children are infected with malaria more than once a year.

In the North-Western Province, competent medical help can be difficult to find. For families living in the remote northern part of the province, across more than a thousand square miles of wild terrain, there is only one place that can ensure a reasonable chance of survival when severe malaria strikes a child: Kalene Mission Hospital. This modest health center, in a decaying brick building capped with a rusty tin roof, represents the front line in the conflict between malaria and man. Scientists at the world's high-tech labs ponder the secrets of the parasite; aid agencies solicit donations; pharmaceutical companies organize drug trials. But it is Kalene hospital—which functions with precisely one microscope, two registered nurses, occasional electricity from a diesel generator, and sometimes a doctor, sometimes not (though always with a good stock of antimalarial medicines)—that copes with malaria's victims.

Every year for a century, since Christian missionaries founded the hospital in 1906, the coming of the rainy season has marked the start of a desperate pilgrimage. Clouds gather; downpours erupt; mosquitoes hatch; malaria surges. There's no time to lose. Parents bundle up their sick children and make their way to Kalene hospital.

They come mostly on foot. Some walk for days. They follow trails across borders, into rivers, through brushwood. When they reach the hospital, each child's name is printed on a card and filed in a worn wooden box at the nurses' station. Florence, Elijah, Ashili. They come through the heat and the rain and the dead dark of the cloudy night. Purity, Watson, Miniva. Some unconscious, some screaming, some locked in seizure. Nelson, Japhious, Kukena. A few families with bicycles, Chinese-made one-speeds, the father at the pedals, the mother on the seat, the child propped between. Delifia, Fideli, Sylvester. They fill up every bed in the children's ward, and they fill up the floor, and they fill up the courtyard. Methyline, Milton, Christine. They pour out of the bush, exhausted and dirty and panicked. They come to the hospital. And the battle for survival begins.


From the mosquito's salivary glands to the host's liver cell: a quiet trip. Everything seems fine. Even the liver itself, that reddish sack of blood-filtering cells, shows no sign of trouble. It's only in those few rooms whose locks have been picked by falciparum where all is pandemonium. Inside these cells, the malaria parasites eat and multiply. They do this nonstop for about a week, until the cell's original contents have been entirely digested and it is bulging with parasites like a soup can gone bad. Each falciparum that entered the body has now replicated itself 40,000 times.

The cells explode. A riot of parasites is set loose in the bloodstream. Within 30 seconds, though, the parasites have again entered the safe houses of cells—this time, each has drilled into a red blood cell, flowing through the circulatory system. Over the next two days, the parasites continue to devour and proliferate stealthily. After they have consumed the invaded cells, they burst out again, and once more there is bedlam in the blood.

For the first time, the body realizes it has been ambushed. Headache and muscle pains are a sign that the immune system has been triggered. But if this is the victim's first bout of malaria, the immune response is mostly ineffective. The alarm has sounded, but the thieves are already under the bed: The parasites swiftly invade a new set of blood cells, and the sequence of reproduction and release continues.

Now the internal temperature begins to rise as the body attempts to cook away the invaders. Shivering sets in—muscle vibrations generate warmth. This is followed by severe fever, then drenching sweat. Cold, hot, wet; the symptoms are a hallmark of the disease. But the parasites' exponential growth continues, and after a few more cycles there are billions of them tumbling about the blood.

By this point, the fever has reached maximum intensity. The body is practically boiling itself to death—anything to halt the attack—but to no avail. The parasites can even commandeer blood cells to help aid their survival. In some cases of falciparum, infected cells sprout Velcro-like knobs on their surfaces, and as these cells pass through the capillaries of the brain, they latch to the sides. The adhesion keeps them from washing into the spleen, which cleans the blood by shredding damaged cells. Somehow—no one is quite sure how—the adhesion also causes the brain to swell. The infection has turned into cerebral malaria, the most feared manifestation of the disease.

This is when the body starts to break down. The parasites have destroyed so many oxygen-carrying red cells that too few are left to sustain vital functions. The lungs fight for breath, and the heart struggles to pump. The blood acidifies. Brain cells die. The child struggles and convulses and finally falls into a coma.


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