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  I thank Dr. Emer and ask him to recommend a hotel in town with nets in the windows. “Just give us nets,” he says as I leave. “Just give us the medicines so we can manage this.”

  I drive to the Lamco B Self-Contained Rooms, a dirty, single-story tin-roofed building that is located, as Dr. Emer said, just past the One Step Bar. The streets are still empty. Only the insane or the newly arrived, I surmise, spend much time out of doors in Apac. Not that there is much to go out for. Among the items on the One Step’s menu is “Dry Pest Meat with Cassava” for $1.50. Neither that nor the two prostitutes slumped across its tiny bar have attracted a single customer.

  Inside the Lamco I am shown behind reception to an internal, windowless courtyard and a door that opens onto a small, equally windowless sitting room, a smaller bedroom, and a tiny attached shower, mine for $3 a night. The bed has a newish-looking net over it, but the screen across the bedroom window, which looks onto a back alley, is torn, and the window won’t close. I find a hole in the shower wall through which I can see clear into the alley. It is filled with rubbish. The toilet is stained and smells stagnant. I try the shower and receive a sharp electric shock from the metal tap. Using a T-shirt wrapped around my hand to work the tap, I wash, cover myself with mosquito repellent, put on a pair of long socks, jeans, and a long-sleeved sweatshirt, take my Malarone pill, get under the net, and lie sweating in the nearly 90-degree heat until I fall asleep.

  The next morning, with a handful of fresh bites on my neck, I drive to Apac District Hospital. The district hospital represents the highest of the four levels of medical care in the Ugandan public health system. On the building’s steps I find Alele Quinto, a young clinical officer, who offers to show me around. He takes me to the pediatric ward and, in a side office, shows me the admissions book. I read the entries.

  OMARA RONALD

  Age: 1 and a quarter. Male. 9 kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.

  OWINY LABAKA ABDIRICHAN

  4 months. Male. 5kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.

  AKAKI AGAI ABDANI

  6 months. Male. 8kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.

  ADANG LOG ROMA

  4 months. Female. 2.4kg. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.

  All babies, all with malaria, all admitted that morning. The previous day there were seven; the day before, nineteen. The treatment is just as alarming. Quinine was phased out in the rich world long ago, after the malaria parasite became resistant. In the most malarious town on earth, the staff at its district hospital are fighting the disease with old medicine, sugar solution, and headache pills.

  Alele takes me to the children’s ward. On entering, we are hit by a warm, sweet stench. There are forty beds in two cramped lines on either side of the room. On each bed are a mother and baby. Relatives squat and lie on the floor. There are no nets over the beds, no fans, and no screens on the ward’s windows, which are wide open. Through one window, I see a child wander outside, squat, and defecate yellow diarrhea onto the ground. Behind him, mothers pound cassava and hang up clothes to dry. Goats and chickens wander through. I notice a tiny tornado of mosquitoes hanging over every bed on the ward. If a child doesn’t have malaria when he or she arrives, the child seems sure to contract the disease during his or her stay.

  Alele introduces me to Judith Adongo, who is on one of the beds cuddling a small baby. Judith is twenty-three and lives with her husband, James, on their small maize and cassava plantation in the swamps. She tells me her four-year-old son, Oscar, has contracted severe malaria seven times. Now it is the turn of his nine-month-old sister, Monica, who is vomiting and running a high fever. I ask James, twenty-seven, how many children he wants. “I need at least five,” he laughs. Then, suddenly serious: “But since malaria is always there, I may have to look for one or two more.” In my reporting, I have become used to hearing the cynical view that malaria is nature’s solution to overpopulation. James’s calculations suggest just the opposite.

  Back in admissions, I meet Sister Adebo Rose. She is trying to find a vein on the back of a baby girl’s hand in which to insert an intravenous drip. Malaria can kill in hours. Mostly, says Sister Adebo, a sick child’s parents, particularly those who can ill afford treatment, will wait until the last moment before making the trip to the hospital, by which time the child’s veins have collapsed from dehydration. Locating a deflated, child-size vein is hard, and eventually Sister Adebo gives up stabbing the girl’s tiny hands and tries the side of her head. The child, terrified, screams throughout. I ask Sister Adebo if the work ever gets to her. She looks at me blankly. “We see them die,” she replies finally. “A lot die.”

  Alele takes me to the maternity ward. It is the same—overcrowded, and all but one of the patients suffering from malaria. I am prepared for suffering, but the sight of a ward of expectant mothers, none rosy-cheeked, none excited, all sick, all way too thin, is still shocking. To try to bring new life into a place like Apac, I realize, is to open the gates to death.

  After showing me around, Alele wants to talk. He has finished secondary school and has ambitions to become a doctor. He has read in a Ugandan newspaper that Apac has the highest rates of malaria transmission in the world. “Some countries are in the news because of their new wealth,” he says. “But in Apac, it’s because of disease.” I tell him my own country, Britain, wiped out malaria half a century before. “No malaria?” he exclaims. “Fifty years ago! Ah! Imagine!” He suddenly looks worried. “We are scared of people who come here from the outside, from places without malaria,” he says. “Every visitor, they get sick. One mosquito bite is enough to put you down forever.”

  A never-ending malaria epidemic is enough to put an entire town down forever. Whereas other human settlements are shaped by their proximity to a navigable river or a natural harbor, or perhaps the discovery of oil or diamonds or gold, Apac is fashioned by malaria. The disease has put a stranglehold on almost any development. What economy does exist is based around administering to the sick and the dead. A five-minute walk down Apac’s main street—Hospital Road—takes me past twelve medical centers, ten pharmacists, and the Nightingale Comprehensive School of Nursing, housed in a crumbling, windowless, single-story brick building. In between is an array of churches and mosques, many with a homemade feel, such as the tiny wood shack on a street behind the Lamco whose sign reveals it is the Voice of Salvation and Healing Church. Even the names of the few general businesses in town—the Sunset Lodge and the Die Hard Electrical Store—seem to have double meanings.

  Apac, very obviously, has a problem. Yet somehow the world has missed it. Signs erected by the side of the road announce the presence of two foreign assistance programs. In a place where malaria can kill hundreds of children a day, the office for a child protection program funded by Germany and the European Union has no malaria program but concentrates instead on what it calls “gender-based violence.” Signs for the Republic of Uganda’s National Wetlands Program, funded by the Belgian Technical Cooperation in Uganda, urge residents to “Protect Wetland. It is our water granary. It stores, filters and purifies.” In case anyone wonders where the program stands on the question of wetness versus human life, it has erected other signs next to stagnant ditches around town that read: “Water Drainage Prohibited.” By banning people from draining the swamps in which their future death is spawned, the program says it is “empowering development.”

  Later Dr. Emer tells me about another benign-sounding foreign initiative: organic farming. In early 2008, he says, he sprayed 103,025 houses in Apac with insecticide, a program paid for by the World Health Organization and other foreign donors. His figures show malaria almost immediately halved. Yet after three months, a court told him to stop. Why? Objections from Uganda’s organic cotton farmers, who supply Nike, H&M, and Wal-Mart’s George Baby line. The farmers claimed their foreign buyers could
not have chemicals anywhere near their cotton if it was to be certified as organic. Chemical-free farming in Africa probably sounds like a great idea in the West, remarks Dr. Emer. The reality is that African babies are dying so that Western babies can wear organic.

  Back at the Lamco, I strike up a conversation with the owner, Lameck Abongo. “Business is terrible,” says Lameck, who is sixty-two. “People don’t come to town. Visitors from the villages just come for small things and go back by night. From Kampala they also just come for the day and make sure they’re gone by dark. And nobody comes at all unless they have a very good reason. Why would they? This is a place of suffering. When you are here, you do not enjoy. In life you need to enjoy, but it’s not possible here.”4

  What persuaded him to open a hotel in the most malaria-infected place on earth?

  Lameck shifts uncomfortably. He had got out when he was younger, he says. For a decade, he ran a dry goods store in Lira, a city two hours away. The business did well. He sent all his eight surviving children (two daughters died of malaria) to schools in Kampala. Then he moved back to Apac and opened up the Lamco. He had high hopes for a family business: Lamco is an acronym for the “Lameck Abongo and Martin Company,” Martin being Lameck’s eldest son. Before the Lamco B, there had been Lamco A, another guesthouse; lack of demand later forced him to turn it into a dispensary. “It was after they built the hospital here,” says Lameck of his move to Apac. “State money seemed to be coming in, and I was convinced by a top official that Apac would be the best. ‘If you go to Apac, you will be rich,’ he said. ‘The government is investing there.’”

  It didn’t happen. The official soon disappeared to Kampala. “I think he died,” says Lameck. “I think maybe he died of malaria.”

  I return twice more to the hospital. The rains have started, and I want to see their effect. By the time I return that night, another ten babies have been admitted. The sweet-sickly smell has intensified, and the ward is spilling over with children and parents. In a corridor, three mothers cradle their babies as Martin, a twenty-seven-year-old orderly, brings them one by one into the small admissions room and tries to fit them with drips. Martin is the only member of staff on duty. He isn’t coping. I watch him try to stick a needle into a four-month-old girl, Doris Amang. He uses a tourniquet to try to raise a vein on the back of one of Doris’s hands, then the other. Next he tries both sides of Doris’s head. She screams and kicks. Martin tries to hold his hand over her eyes and turn her head away. Twice he sends her back into the corridor to calm down. Eventually, after pricking her ten or twelve times, he gives up. The windows are wide open. As I watch, a mosquito buzzes around his head and settles on Doris’s cheek.

  After a second night at the Lamco, and sporting more bites, I wish Lameck good luck, check out of my room, and head to the hospital for a final visit. Martin is long gone. There are no other staff. A rough head count confirms ten more kids have arrived, making fifty in all. The ward is out of beds, and the new arrivals are sleeping on flattened cardboard boxes in the corridor.

  I realize the mothers are looking to me. I have nothing to offer them. I leave the ward, walk quickly to my car, and drive for the gates. Ahead of me is a naked street walker, feeling his way along the fence. As I roar past him, I catch a glimpse of a startled, emaciated expression. I turn onto Hospital Road and drive back through town. I race through the empty streets. I don’t stop until I reach Kampala.

  CHAPTER 2

  Original Sickness

  Malaria covers the globe. It stunts whole continents. As well as killing one million people a year, it infects two hundred fifty million to five hundred million more. In lost work days, unnecessary expense, and wasted potential, the development economist Jeffrey Sachs reckons it costs Africa $12 billion a year, a figure Ray Chambers has revised to $30 to $40 billion. Fixing malaria would, no doubt, be a colossal boost to health and development. But that begs the question: why hasn’t it been done? The answer is stark: malaria is the oldest challenge in medicine because it is one of the hardest. Many scientists and development specialists doubt it can be done.

  Compared to malaria, humans are evolution’s gate-crasher. Scientists date the origins of the disease to microscopic protozoa that existed hundreds of millions of years ago, long before the birth of most species. Those protozoa would most likely have lived in water as plantlike algae—hence some cells in the modern malaria parasite still carry plastids, genomes that indicate a previous ability to photosynthesize. Living alongside insect eggs and larvae on the water’s surface, these ancestors of malaria gradually adapted to become parasites living in the guts of those larvae.

  Further evolution followed. When larvae became insects and took flight, malaria went with them. When warm-blooded animals arrived, and when female mosquitoes became bloodsuckers, the malaria parasite adapted to live inside red blood cells—where it was protected from its new host’s immune system. And when insects began to specialize in different blood sources—birds, lizards, mice, rabbits, bats, squirrels, porcupines, monkeys, apes, and people—so did the malaria parasite. Today, after eons of evolution, there are four hundred fifty different recognized species of the malaria parasite Plasmodium, and another is identified every few years.

  The human malaria parasite is especially complex. It is composed of around five thousand genes and during the course of its life takes on seven distinct forms on its journey from mosquito gut to human bloodstream and back again. Those changes account for the delay in the appearance of the disease’s symptoms—a person bitten by a malarious mosquito will not come down with fever until after the parasite has traversed the bloodstream, infected the liver, multiplied, then burst back out into the bloodstream, a process that takes a minimum of six days. These shapeshifting properties are also one reason why the disease has proved so hard to beat.1

  Several thousand years ago, two dominant strains of human malaria parasite emerged, Plasmodium falciparum and Plasmodium vivax, with the former the more deadly and widespread of the two.2 At the time, organized agriculture was spreading from the Fertile Crescent in the Middle East to Africa. Humans were leaving behind a hunter-gatherer existence and settling into densely populated villages, often in cleared tropical forest and next to water. That was a stroke of luck for the local Anopheles mosquito: not only had humans stopped moving and now presented themselves as stationary targets, but they were doing so close to the rivers and lakes in which mosquitoes could breed. The Anopheles population exploded. So, naturally, did malaria.

  From Africa, Plasmodium falciparum and vivax spread out across the world. Epidemiologists measure a disease’s contagiousness by a reproductive number—the number of cases one would expect to see from a single founding case. Malaria turns out to be the world’s most contagious disease, with a reproductive number of anywhere from 10 to 3,000. (By comparison, the reproductive number for H1N1, or swine flu, is 3.)3

  The key to malaria’s wide spread is not the virus itself nor its carrier, the mosquito, which can only fly five miles and live for two weeks. It is us. Humans travel further and wider than any other animal. And as Africans ventured out into the world, wherever they went, they carried the malaria parasite in their blood. China might have known about malaria 5,000 years ago: the 4,700-year-old canon of Chinese medicine, the Nei Ching, mentions recurring fevers that enlarge spleens, classic symptoms of malaria. Texts dating from the same time found in Sumeria (now Iraq) and Egypt also speak of malarialike fevers. Evidence of falciparum was found too in 40 percent of the collection of Egyptian mummies at the Turin Museum, which date from 3200 BC.4 Over the millennia, the disease spread around the Mediterranean and into Europe, reaching northern Europe in the Dark Ages. It moved onto the Americas a few centuries later with the advent of colonization and the accompanying trade in African slaves.

  Malaria’s global reach has given it an unprecedented impact on human history.5 Moving east to west, in Asia malaria is thought to have stopped Alexander the Great in India in 326 BC and killed Gengh
is Khan a millennium and a half later. In Asia and Africa, it determined patterns of colonization and development. Malaria made the tropical forests, thick bush, and swamps of much of Africa’s interior a no-go area for Europeans—60 percent of missionaries sent to West Africa between 1804 and 1825 perished6—and to this day, big cities on the continent either cling to the coast or, in the interior, to high ground. But while malaria killed off European explorers, it allowed the comparatively malaria-immune Bantu tribes from West Africa to spread east and south. Their descendants—the Kikuyu in Kenya, the Shona in Zimbabwe, and the Xhosa and Zulu in South Africa—remain dominant today.

  Further north in Egypt, malaria killed the boy pharaoh Tutankhamen in 1324 BC.7 In Italy, it determined who ruled much of the known world. Malaria precipitated the first fall of Rome, so weakening its defenders that they were unable to beat back attacks by the barbarian Prince Alaric in 410 AD—then decimated Alaric’s forces as well. It prompted the relocation of the Vatican in 1574 after the death of numerous popes and, centuries later, helped spur mass Italian emigration to the United States. So associated was malaria with Italy that the disease took an Italian name: “mal’aria,” meaning bad air, after the foul swamp vapors originally thought to carry it.

  Across the English Channel in Britain, malaria killed Oliver Cromwell in 1658 and nearly claimed his royal successor Charles II during a London malaria epidemic in 1678. A few decades later, it helped end Scottish independence: so devastated by the disease were late-seventeenth-century Scottish settlers hoping to colonize the lush, fertile jungles of Panama that it ruined the finances of their homeland and, in 1707, forced Scotland to accept English rule in return for London’s assumption of its debts. Once inside the Americas, malaria went on to infect eight presidents, the last of which was John F. Kennedy. It also helped set the tone for centuries of racial antagonism. In the eighteenth and nineteenth centuries, African slaves’ superior immunity to the disease propelled their population to majorities in the southern states. The threat such a numerical advantage implied sowed the seeds of segregation, a system originally conceived by the white ruling elite as a defensive response to the end of slavery. Some say malaria even explains how the nation of the 1773 Boston Tea Party became today’s land of the latte: in the nineteenth century, coffee, which has a chemical structure and bitter taste similar to quinine, was widely believed to protect against the disease.8