Dr Seuss Does Malaria

NEWSMAP, United States Military, 8 Nov. 1943

This Malaria map was illustrated by Theodor Seuss Geisel, better known as Dr. Seuss, during World War II to educate young GIs. According to the Naval Department Library, this map was printed on the back of a Newsmap (two sided poster) that showed the five war fronts in 1943: Russia, Italy, “air offensive”, southwest Pacific and Burma.

The text as transcribed by the Navy Department Library reads:

THIS IS ANN…..she drinks blood!

Her full name is Anopheles Mosquito and she’s dying to meet you. Her trade is dishing out MALARIA! If you’ll take a look at the map below you can see where she hangs out.

She can knock you flat so you’re no good to your country, your outfit or yourself. You’ve got the dope, the nets and stuff to lick her if you will USE IT.

Use a little horse sense and you can lick Ann. Get sloppy and careless about her and she’ll bat you down just as surely as a bomb, a bullet or a shell.

This text is taken from a booklet done by Theodor Geisel to train soldiers or sailors during the war. Cartoon educational materials were probably fairly effective. Newspaper cartoons were very popular at the time and the average GI was very young. Many (if not most) of these soldiers/sailors dropped out of school, often in grade school, to work during the Great Depression so educational materials had to be targeted at a lower reading level that modern military materials.

Since this is now a 60+ year old government publication, I will assume that its public domain. I found this at the Young Dipterists website. “What to do about Ann” was apparently a header on each page after the first page. I’ve tried to reproduce it as well as I could. The site appears to be missing the last page(s) since the last page has a “turn the page”.

Mapping Malaria in Anglo-Saxon England

Guthlac at Croyland in the marshes of the Wash.

England once looked very different. Much of southern Britain was marshland for most of the island’s occupied history. These bogs, fens, and marshes ensured that areas of virtual wilderness persisted  from before Roman Britain through the Norman period and beyond. Despite the difficulties of using fenlands, these areas were not only occupied throughout the Anglo-Saxon period, but important centers like Croyland, Bardney, and Ely eventually developed in the marsh.

The largest fenland region was known as ‘the Wash’.  This low-lying region drained four rivers into  a square bay of the North Sea that forms the corner between Lincolnshire and Norfolk. In Anglo-Saxon times, this tidal marsh and bog was a vast border region between the region of Lindsey and East Anglia.  Places like Croyland and Ely were islands in the wetlands.  The eighth century Life of Guthlac describes the environment of Croyland when Guthlac arrived:

There is in the Midland district of Britain a most dismal fen of immense size, which begins at the banks of the river Granta not far from the camp which is called Gronte (Cambridge) and stretches from the south as far north as the sea. It a very long tract, now consisting of marshes, now of bogs, sometimes with black waters overhung by fog, sometimes studded with woodland islands and traversed by the windings of tortuous streams. (Hill, 1981:11 cited in Gowland & Western, 2011).

These marshes are ideal for malaria, but evidence of malaria in Anglo-Saxon England has been lacking. It is supposed that malaria would have been brought to Britain with the Romans (1). Unfortunately, there is no evidence that I know of that malaria became endemic in Roman Britain much less lasted into the early medieval (Anglo-Saxon) period. It has also been speculated that ‘spring fever’ (lecten adl) found in Anglo-Saxon leechbooks is the spring manifestation of tertian malaria (1) caused by Plasmodium vivax. This would fit the pattern of malaria in cool or cold climates like that found in Finland discussed in a recent post. Indoor transmission in Anglo-Saxon earthen floored, open structured wooden homes with thatched roofs would be an ideal way to concentrate malaria in a thinly populated marsh.  (Without chimneys homes had to open enough to allow smoke to escape from a central hearth.)

Incidence of Malaria in England, 1840-1910 (2)

It has long been known that Britain can environmentally support endemic malaria. Malaria was fairly wide-spread in 19th century Britain when it was first mapped (figure to left) (2). The upper black area on the map includes much of ‘the Wash’. However, proof of malaria is more tenuous for the medieval period.  Together with the unhealthy reputation of the brackish marshlands there is at least enough evidence to suggest that endemic malaria reached back into the late medieval period.

Malaria went by a variety of local names before the early modern period. Malaria-like fevers are mentioned in literature from Geoffrey Chaucer to William Shakespeare (2, 3). Terminology for malaria was not settled upon the Italian ‘malaria’ until the early modern period. Before then, it went by a variety of terms the most universal being ‘ague’, meaning the shakes, and sometimes  ‘fever and ague’ referring to the cyclic breaking of a fever.

Gowland and Western (2011) took a new approach to finding evidence of malaria in Anglo-Saxon England (400-1100 AD) (4). Malaria caused by Plasmodium vivax causes chronic hemolytic anemia that may result in cribra orbitalia due to expansion of the bone marrow in the cranium. Gowland and Western correlated the presence of cribra orbitalia in Anglo-Saxon skeletal remains with the presence of the malarial vector Anopheles atroparavus and reports of ‘ague’ in 19th century England.

The Anglo-Saxon cemeteries used in their study are mapped in the figure below on the left. Note that not many cemeteries are located near the modern coastline of ‘the Wash’. This area would have likely been too wet for settlement.

Anglo-Saxon cemeteries (4)

Map of A. atroparvus with 19th century "ague" records. (4)

Gowland and Western  determined areas capable of sustaining malaria by mapping the presence of A. atroparvus from a 1900 AD British Museum survey (shown above on the right) (4).  The darker the shading the more reports of mosquitoes. This survey was reported to not have been systematic, so they augmented it with 19th century ‘ague’ reports (triangles).  There are some notable areas with high levels of mosquitoes that lack ague reports. This map was use to determine malarial regions for correlation with either cribra orbitalia or the poor nutrition control enamel hypoplasia. It also roughly correlates with the 1840-1910 malaria incidence in the color map above by Kuhn et al (2).

An inverse distance map showing A. atroparus incidence vs. hot and cold spots for cribra orbitalia. (4)

In this last map, malarial areas are plotted with hot and cold spots for cribra orbitalia.  Purple and blue areas on the map indicate the highest areas of A. atroparvus in 1900, while red and orange circles indicate the cribra orbitalia ‘hot’ spots. Areas of cribra orbitalia correlate very well with malarial areas around the Wash.  Cribra orbitalia ‘cold’ spots (blue circles) correlate with areas of low A. atroparvus. They found no correlation between enamel hypoplasia with either ‘malarial’ or ‘non-malarial’ areas (4).

If this cribra orbitalia is due to malaria, it is likely an underestimate of the amount of malaria in the English wetlands. Cribra orbitalia forms in children so it will not indicate adults who contract malaria. Communities like Ely, Croyland and Peterborough were large monasteries who probably drew many into the marsh as adults.

Confirmation of malaria in Anglo-Saxon England will have to wait for molecular evidence, but this skeletal evidence strengthens the hypothesis that it was endemic in early medieval Britain. It also should be informative for the areas to concentrate efforts to find molecular evidence.

References:

(1) Cameron, M.L. (1993, repr. 2006) Anglo-Saxon Medicine. Cambridge University Press.

(2) Kuhn, K., Campbell-Lendrum, D., Armstrong, B., & Davies, C. (2003). Malaria in Britain: Past, present, and future Proceedings of the National Academy of Sciences, 100 (17), 9997-10001 DOI: 10.1073/pnas.1233687100

(3) Reiter P (2000). From Shakespeare to Defoe: malaria in England in the Little Ice Age. Emerging infectious diseases, 6 (1), 1-11 PMID: 10653562

(4) Gowland RL, & Western AG (2011). Morbidity in the marshes: Using spatial epidemiology to investigate skeletal evidence for malaria in Anglo-Saxon England (AD 410-1050). American journal of physical anthropology PMID: 22183814

Contagions Round-up 20: Past is Prologue in Science too!

Congratulations to Wonders & Marvels for winning the Cliopatria Award for Best History Group Blog of 2011 and to Lindsey Fitzharris of The Chirurgeon’s Apprentice who won the Cliopatria Award for Best History Individual Blog of 2011. What a year for history of medicine!

Starting with Lindsey’s latest post, let’s get this round-up rolling. The Chirurgenon’s Apprentice started the new year with a post on Cold Like the Dead: Learning Dispassion through Dissection.

Marri Lynn of Wonders and Marvels writes about the many medicinal uses Nicolas of Poland found for snakes.  Elizabeth Fix also of Wonders & Marvels writes about the search for immortality and the Philosopher’s Stone. Adrienne Mayor of Wonders & Marvels tells us that the quest for stem-cell like rejuvenation is ancient indeed!

Eric Michael Johnson of Primate Diaries discusses uses of the past by scientists and science writers.

Caroline Rance of The Quack Doctor reviews Moore’s Shropshire Doctors and Quacks.

Here at Contagions, I looked at a study of malaria in 18th century Finland and the process of retrospective diagnosis today.

Katy Meyers of Bones Don’t Lie looks at malaria trends in the UK and the discovery of brucellosis in medieval Albanian remains.

Kristina Killgrove of Powered by Osteons takes on a recent paper on the plague of Athens in the play Oedipus Rex, shares some material on ethics in bioarchaeology (part 1: Americas), and skeletal evidence of lead poisoning in ancient to medieval Rome.

Maryn McKenna of Superbug has been on the trail of completely resistant TB in India and in Italy.

On the other hand, Vincent Racaniello of The Virology Blog celebrates India’s polio free anniversary, and reassessed the mortality rate of ebolavirus, and discusses the recent moratorium on influenza H5N1 transmission research.

Zoonotica writes about the importance of bovine TB that is causing the planned cull of badgers in Britain.

Tara Smith of Aetiology writes about some of her recent research on MRSA in pork products.

Jennifer Frazer of The Artful Amoeba writes a scary finding on the durability of noravirus (Norwalk virus).

Michael Walsh of Infection Landscapes writes on our ancient passengers the Helminths (worms).

Small Things Considered took a look at what’s so scary about restroom microbiota.

Malaria Near the Arctic Circle

Malaria study area (Hulden et al, 2005)

When I think of Finland, malaria just doesn’t normally come to mind. Although northern climes often have swarms of mosquitoes, its hard to imagine mosquito-borne infections gaining much traction in the short summer season. Yet defying imagination, malaria has thrived in northern Finland, Sweden and Russia near the arctic circle in the past. In the late 19th and early 20th century, Plasmodium falciparum and Plasmodium vivax caused outbreaks in northern Europe. Despite the outbreak of P. falciparium at Archangelsk in the 1930s, P. vivax is believed to be the primary malarial species in northern Europe.

Finnish researchers Lena Huldén, Larry Huldén, and Kari Heliövaara focused on the 1800-1870 period in southern Finland as having the ideal demographic, medical and temperature records before the advent of quinine to study malaria transmission in cold climates.

Medical records are available for Finland from annual reports of ‘district physicians’ and local ministers for most of the 19th century. Doctors were stretched thin across Finland but in the fifty years between 1826 to 1870 there were 542 reports of malaria. Ministers were required to record the cause of death of their parishioners from 1749.  Digitization of parish records by the Finnish Genealogical Society has made this data available online for 1800-1850. Terms used for malaria were specific enough that general fever terms in the records did not correlate with malaria outbreaks or temperatures.

Malaria isn’t recorded in Finland until the 17th century, probably brought by migrant workers and gained traction among people gathered for summer infrastructure projects in southern Finland in the 18th century. Death records and physician reports indicate that during mid-19th century epidemics the mortality rate reached as high as 3% of the population with 7-20% infected. The worst epidemic occurred in 1862.

There are three Anopheles mosquito species found in Finland. All are believed to have been present in Finland since prehistory.  It had been thought summer temperatures of 16 C (60.8 F) were required to maintain endemic malaria, but malaria has been recorded areas in of northern Sweden and Finland that don’t reach 16C in the summer. Males die shortly after mating and female Anopheles must hibernate from late summer until well into spring. Therefore, the female spends most of its life indoors hibernating with humans and sheltered domestic livestock. The female will take sporadic nocturnal blood meals over the winter but won’t lay her eggs until spring.

Huldén,  Huldén, and Heliövaara correlated malarial deaths with annual, seasonal and monthly temperatures. The only significant correlation occurred between summer temperatures of the previous year, but not at all with annual or seasonal temperatures of the same year. Malarial deaths peaked in the spring rather than the usual late summer or autumn. So how does this work with a temperature correlation to the previous summer? Winter infections. The previous summer temperatures effect how many mosquitoes will be hibernating over the winter in homes. Sporadic blood meals over the winter in the confined space of the home spreads the infection to most of the humans and other hibernating mosquitoes causing infections that peak in the spring. Humans are the primary reservoir of infection in cold climates. It doesn’t matter that the malarial sporozoites won’t mature outdoors during the cool summer because they will mature in the cozy confines of winter homes. Fatal spring infections in 40-50 infants born in the winters from 1750 to 1850 supports the theory that the female mosquitoes were capable of transmitting malaria for the entire winter.

Age distribution among the malarial deaths was very similar to the total population indicating that all ages groups were equally vulnerable to infection. Huldén,  Huldén, and Heliövaara interpret this as indicating infection occurred at a time when the entire family would be together in heated buildings, in the winter rather than in summer when  occupations cause families to live apart by age and gender often in unheated buildings.

Epidemiological data can usually be explained but not necessarily predicted. They have provided another example of why epidemiology can’t always be definitive in ruling in or ruling out the diagnosis of a historic epidemic. Based on outdoor temperatures malaria should have never been endemic in Finland at all. This study highlights the importance of the indoor environment for malaria (and other zoonoses).

Reference

Huldén L, Huldén L, & Heliövaara K (2005). Endemic malaria: an ‘indoor’ disease in northern Europe. Historical data analysed. Malaria journal, 4 (1) PMID: 15847704

Mapping Smallpox, Malaria, and Leprosy

Contagion by Haisam Hussein of Lapham's Quarterly (Click the map to enlarge)

I love looking at infection maps. Hat-tip to Michael Walsh at Germscape for finding this map. There is a lot of information on this map and unfortunately any text that might have come with it at Lapham’s Quarterly is not readily available. So we have the map to figure out without any explanation. The red arteries represent the origin of Leprosy in central Africa and the blue veins represent the origin of smallpox in northern Africa and its spread. Transmission lines for malaria are not shown; the yellow areas seem to represent modern endemic malaria. The geographic highlights either document transmission events or major steps in the study of malaria, smallpox and leprosy.

Malaria deaths in the United States, 1870 census.

At the height of its expansion, there are few places on earth that malaria did not penetrate. Today malaria is found primarily in tropical regions but that wasn’t always so. The map to the right illustrates the malarial deaths listed in the 1870 US federal census. Malaria once was endemic, at one time or another, in most of the United States east of the Mississippi River and around the Gulf of Mexico. Likewise it was endemic in parts of 19th century Britain. In temperate regions of the world it is the humans who carry the parasite through the winter and infect the spring mosquitoes. Contrary to general knowledge, most malaria in the United States dwindled long before the arrival of DDT. Improving the standard of living and eliminating unnecessary standing water are the most important ways to decrease malaria. Early American physician Benjamin Rush knew this over two centuries ago.

 

Benjamin Rush on Malaria in Pennsylvannia, 1785

Benjamin Rush was the best known physician in early America. In the second volume of the Transactions of the American Philosophical Society, Rush wrote an essay giving his views on the increase of bilious and intermittent fevers (malaria) in Pennsylvania in recent years.

Rush outlined three reasons for the increase:

1. A proliferation of mill-ponds and the blockage of free-flowing streams to create these mill-ponds.
2. Cutting of forests.
3. Unequal rainfall in the previous seven years

Rush primarily focuses on deforestation as the cause for the increased malaria. He dwells quite a bit on his recollections that these fevers used to only occur with a half mile of creeks and rivers but can now be found up to ten miles from the river.

“It has been remarked that intermittents on the shores of the Susquehannah have kept an exact pace with the passages which have been opened up for the propagation of marsh effluvia, by cutting down trees that formerly grew in the neighborhood. … I beg a distinction be made here between clearing and cultivating a country. While clearing a country makes it sickly in a manner that has been mentioned, cultivating a country, that is, draining swamps, destroying weeds, burning brush,  and exhaling an unwholesome or superfluous moisture of the earth by means of frequent crops of grain, grasses and vegetables of all kinds, render it healthy. I could mention, in support of these facts, countries in the United States, which have passed through each of the stages that have been described. The first settlers received these countries from the hands of nature pure and healthy. Fevers soon followed their improvements, nor where they finally banished, until the higher degrees of cultivation that have been named took place. I confine myself to those countries only where the salutary effects of cultivation were not rendered abortive by the neighborhood of mill-ponds.” (Rush,  206-207)

Rush is clearly linking all forms of shallow, standing water with the occurence of malaria, then called bilious fever or intermittent fever.  Mosquitoes had not yet been identified as the vectors of malaria.

From the 13th and 19th centuries, Malaria went by several names: ague, ague and fever, bilious fever, intermittent fever, remittent fever, tertian fever, quartan (fever), marsh fever (England), autumnal fever, swamp fever, and blackwater fever. The Italian name for the fever, malaria, meaning bad-air, did not become nearly universally accepted until at least c. 1900.

Interestingly one of the supporting observations Rush gives for his theory on the relationship between water and malaria, is the  appearance of Egyptian fevers when the flood water recedes. Rush is still supporting the miasma theory of illness. He contends that the Egyptians are safe while the flood waters are present because the water is covering the earth so that it can’t release its sickly vapors. Later when the flood recedes the earth is moist but not covered,  the sickly vapors can be released to cause  the fevers. (As discussed before, one of the fevers that followed Egyptian floods was actually plague, although King Tut’s malaria indicates that it was present in some part of early Egypt.)

Rush’s suggestions for decreasing malaria in Pennsylvania include planting more trees around mill ponds. He claims to know of cases were families were saved from fevers by having a copse of trees between the mill-pond and their home. He suggests that the trees give mechanical and chemical protection. Mechanical protection comes from shading the water, preventing the production of bad air and by blocking the passage of vapors from the pond. Chemical protection comes from the trees ability to absorb unhealthy vapors and release purified air called “‘deflogisticated’ air”. Rush claims that experiments by Mr. Ingenhausz have proven that willow trees clean the air better than other types of trees.

His second suggestion for reducing the recent fevers is to make sure that cultivation kept up with the clearing of the land.

“Nature has in this instance connected our duty, interest and health together. Let every spot covered with moisture from which wood has been cut, be carefully drained, and afterwards be ploughed and sowed with grass feed; let weeds of all kinds be destroyed, and let the waters be so directed as to prevent their stagnation in any part of their course.” (Rush,  209)

Rush knows that these suggestions will take some time to implement so he makes more suggestions for the meantime.

1. Fire, smoke or heat destroys the ill effects of marsh miasma on the human body. Rush advises large fires be lit every night between homes and the sources of marsh vapors until there have been two or three frosts. He also advises that fires be kept lit during the ‘sickly season’ in sleeping rooms for the same reason even when the heat is such that the windows must be kept open.
2. He advises people in sickly situations to wear wool or cotton rather than linen. He claims that the most sickly parts of Jamaica have been improved since the people began wearing wool or cotton rather than linen. He also reports that during the war (the revolution) officers were kept healthy by wearing woolen shirts or waistcoats against the skin. He notes that the British Parliament requires that the dead in Britain be buried in a woolen shirt or winding sheet. Rush contends they would be better served by requiring the living to wear wool and wrap the dead in linen.
3. The sickly summer season is the time for generous food and drinking wine or beer rather than water or spirits. Rush admits that vegetables do not cause fevers but believes because of general weakness during the sickly season more animal products should be eaten. For some reason though he thinks salted meat is better than fresh meat in the summer.
4. Avoid the evening air under all circumstances. Drink “bitters” before breathing even the early morning air. (These bitters seem to be bitter teas made from wood products like wormwood or willow bark.) He remarks that bitters made with wine or spirits can’t be consumed in enough volume to help without intoxication.
5. Clean linens and wash frequently. He claims that adding salt to wash water in Jamaica decreased disease. Offal should be removed from near the house but dung from domestic animals can be excepted. “Nature, which made man and these animals, equally necessary to each others subsistence, has kindly prevented any inconvenience from their living together” (Rush, 212). He believes that domestic dung/manure counteracts the effects of marsh vapors. He notes that European cottagers often live in the same building with their cattle and remain healthy. Rush claims that areas of Philadelphia with livery stables have fewer fevers.

Although Rush does not recognize the role of mosquitoes in spreading malaria, his advice mostly decreases mosquito bites. Smoke, thicker clothing, cleanliness and avoiding night air should all decrease (but not eliminate) mosquito bites. Keeping domestic animals nearby will give the mosquitoes targets other than humans. Avoiding night air, burning fires to drive away mosquitoes, and planting willow trees near ponds remained part of American folk practices for generations after the malaria was gone.

________________________

References:

Benjamin Rush, (16 Dec 1785)  “An inquiry into the cause of the increase in bilious and intermittent fevers in Pennsylvania with hints for preventing them.” Transactions of the American Philosophic Society, vol. 2, p. 206-212.

Benjamin Rush, Professor of Chemistry at the University of Pennsylvania, read this paper on 16 December 1785.

For more information on malaria in early America see these papers:

Kukla, Jon. 1986. “Kentish Agues and American Distempers: The Transmission of Malaria from England to Virginia in the Seventeenth Century” Southern Studies 25(2): 135-147.

Rutman, Darret B and Anita H. 1976. “Of Agues and Fevers: Malaria in the Early Chesapeake” The William and Mary Quarterly. Third series.  33 (1): 31-60.

A Reversal of Seasons

Mortality rates by month in Chicago in the 1870s and 1922. Isaac Rawlings et al, The Rise and Fall of Disease in Illinois, State Department of Health, 1927.

In the last post I mentioned that the federal mortality census can inform us of the seasonality of disease in the mid-nineteenth century. This chart illustrates the seasonality of death in Chicago during the 1870s and in 1922. The solid line represents the average deaths per month during the 1870s, while the lower dotted line represents deaths in 1922.  As you can see, Chicago experienced a nearly complete reversal of seasonal mortality. In the 1870s, deaths peaked in July and slowly declined through the autumn. By 1922 the summer months are the safest months of the year with the lowest death rates. Seasonality largely exists because the primary cause of death in the 19th century was infectious disease, and the major diseases displayed a marked seasonality. So malaria and gastrointestinal diseases like typhoid fever are more common in the summer and autumn, while all  infectious respiratory diseases are more common in the winter.

From what we know of common nineteenth century diseases summer had almost certainly been the deadliest season for most if not all of the nineteenth century. Statewide, the 1870 Illinois federal mortality census records cholera infantum, pneumonia, scarlet fever, typhoid, meningitis, dysentery and diarrhea as the most common causes of death (p. 98).   Yet these causes of death amount to only one third of all deaths. In the same year, children under 5 years were 50.3% of all deaths with children under age 1 accounting for 27.3% of the 33,672 deaths reported that year. Looking at Chicago alone, children under age 5 accounted for 62.8% of all deaths in 1870, but it dropped to 17.8% in 1925.

Consumption  or tuberculosis is a dark horse lurking in data. Deaths by consumption are not listed in the summary of the 1870 federal mortality census, but somehow they came up a death rate of 145.6 per 100,000 people in 1870. In 1922, they record 5,620 deaths or 83.3 deaths per 100,000 people (p. 364). For the topic at hand though, data for tuberculosis cases and deaths shows no seasonality to either.

The state health department credited the reversal of seasons to “the disappearance of malaria, the near disappearance of typhoid and the great decrease in diarrhoeal diseases and other causes more or less related to the work of the health departments” (Rawlings et al, p. 90).  The winter peak began to appear in the 1870s and continued to grow until the 1920s. The state department credited this rise almost entirely to pneumonia and influenza (Rawlings et al, 1927). We have to remember that there were major pandemics of influenza in 1892 and 1918. In the final chapter of The Rise and Fall of Disease in Illinois the health department summarizes their success against all the major diseases. For influenza they list just one line: “There has been no success in combating influenza.” (p. 404)

Source:  Isaac Rawlings et al, The Rise and Fall of Disease in Illinois. The Health Department, 1927.