The history of Malaria in Temperate europe

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The History of Malaria in Temperate Europe

In recent times, the idea that malaria is and always has been strictly a tropical disease has become a common belief. In other words, there exists a belief that malaria has never been and could never be a problem in countries in temperate climate zones like the nations of Europe and Canada. The basis of this belief lies in the assumption that malaria is a disease whose range and demographics are determined predominantly by climate and temperature. Specifically that malaria requires temperatures in excess of those found in the Northern temperate regions. This assertion is however completely inaccurate. In fact, malaria has been found as far north as the city of Archangel located in the Arctic circle

Malaria has been a scourge of Europe practically since the beginnings of European civilizations. It should be noted here that it is difficult to know quantitatively the exact history and epidemiology of malaria in ancient Europe (or indeed any other disease). The historical records of most time periods with regards to dangerous diseases and their effects tend to be rather incomplete. Compounding this difficulty was the fact that early European physicians due to their lack of knowledge of modern medicine tended to misdiagnose the cause of many diseases.

Indeed, the discovery of the cause malaria (Plasmodium malariae)only occurred in the year 1880 when Alphonse Laveran observed sporozoites of this parasite present in a sample of blood from a patient suffering from intermittent fever. In spite of these difficulties, medical historians have been able to find descriptions of diseases in history that very closely match those of the pathology of present-day strains of malaria.

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L. W. Hackett observes that in ancient Greece, "Hippocrates in the fifth century B.C. was acquainted with the swellings of the spleen among inhabitants of marshy regions". Hackett also notes that "the cult of the Fever Goddess in Rome was extremely old". De Zulueta and Bruce-Chawatt offer further proof of the existence of malaria in Rome when they note that the Roman Varro "emphasized that a house should be built in a high and well ventilated place so that small 'bestiole' that are bred nearby should be blown away" In fact, the presence of malaria in Italy was a fact of life until the year 170 whereby the World Health Organization declared that Italy was finally free of malaria.

European nations that were farther north than the Mediterranean peninsula unfortunately were not spared the depredations of the various Plasmodium species and all the major nations of Europe had regions within their national boundaries that were endemic to malaria. For instance, certain parts of England suffered the presence of 'marsh fevers' and 'agues' such that areas like Essex near saline marshes were studiously avoided by all who could afford to and noted for their unhealthiness. It is the purpose of this paper to explore the extent of malaria in Europe (including the United Kingdom) and identify the factors that influenced its eventual decline and disappearance from the Western world that began in some parts of Europe as early as the 17th century.

If anything, the above stated example of malaria finding its way to the city of Archangel amply demonstrates the inadequacy of the idea that climate alone influences where malarial parasites can take root. Nonetheless, it is still true that as of 175, Europe was declared free of malaria. It is therefore necessary to search for other alternative factors that will explain the notable absence of a disease that is otherwise rampant in many parts of the world, particularly the third world. Many medical historians recognizing the weaknesses of the 'climate' hypothesis have claimed that the decline of malaria in Europe is actually more closely related to the rapid and deep changes that European society went through as it changed from a subsistence-agrarian society to a modern industrial state society from the 17th century to the present.

For instance, during this time period, European society began to develop new and more productive methods of agriculture such as the implementation of crop rotation which ended the need of European farmers to let at least one third of their fields go fallow at any given time. This coincided with the discovery of root plants that in addition to replenishing the soil with nitrogen and other nutrients were also made good feed for livestock during the winter months when grazing was difficult or impossible. It was this development that made viable for the first time, the production of livestock beyond the subsistence level. Prior to this, farmers were unable to produce the numbers of livestock that would have made separate housing for their beasts necessary and more often than not animals resided in close proximity with their masters.

The creation of separate housing for livestock and farmers is one of the factors that has been correlated to the decline of malaria in Europe. Hackett notes that stables are attractive environments to Anopheles maculipennis mosquitoes, the most important vector of malaria in the Dombes and Camarque areas of France since these mosquitoes tended "to frequent places which offer a nightly food supply and which are dark, humid, warm and relatively free from draughts." As well, in Switzerland, it has been noted that the "rise of cattle" and "greater stabling in winter" contributed to the decline of malaria that nation. Germany also experienced a decrease in the 1th century that coincided with the "draining of marshes and better agricultural practices." The history of malaria in Belgium also reflects this trend of the incidence of malaria infection to decline as agricultural practices improved. The case of malaria in England also supports this correlation as by the early twentieth century, "dark, ill-ventilated, stables, byres and pigsties or old-fashioned cottages with low roofs, ribboned with cobwebs, were teeming with mosquitoes in the English marshes but they were rarely collected from well-ventilated 'modern' human habitations." In effect the division of habitations of livestock and humans into physically separated locations combined with trend of human habitations that were brighter and better ventilated (and hence less hospitable to mosquitoes of the Anopheles varieties) more than likely affected the rates of infection in malaria endemic zones.

Another factor closely related to the development of agriculture in Europe that had a tremendous effect upon the distribution of malaria in Europe was the draining of marshes and the creation of dykes to claim new arable land for development. It was noted by most of the inhabitants of England in the time of Daniel Dafoe (author of Robinson Crusoe) that it was far more likely to get seriously ill in certain areas of the country. In particular, there existed a "contrast between the healthy 'airs' and 'waters' of some coastal places (in England), especially those with chalk landscapes, and the unhealthiness of marshy coastal and estuarine localities." The unhealthiness of saline marsh areas in England was so pronounced that "vicars rarely lived their marshland parishes, so fearful were they of the 'agues' and 'marsh fevers'." As it happens, saline marshes and estuarine areas are the preferred breeding areas of Anopheles Atroparvus, the principal vector of malaria in England. Furthermore, A. atroparvus is still present in England and its current distribution matches very closely the regions of England formerly associated with endemic 'marsh fever'. It therefore stands to reason that the draining of marshes that were 'brackish' in nature would have affected the mortality and morbidity rates of endemic malaria those areas near the aforementioned marshes. The historian Mary Dobson corroborated this observation when she noted that "Whitley concluded that the decline of malaria was the result 'in very nearly every case' of one cause - improved land drainage." The positive affects of the removal of breeding habitat of the Anopheles mosquito upon the rates of malaria was also demonstrated in Italy during the 10s. In this time period, "the reclamation of 00,000 acres of marshland in the depopulated Pontine marshes that allowed for the settlement of nearly 100,000 people." Not all of the efforts of humankind to alter the environment have been as successful in terms of the reduction of malaria. For example, Bruce-Chawatt and de Zulueta observe that in 1th century France, the town of Narbonne became malarious when it cut down the neighboring forests, turning the adjacent salt lakes into marshes. Mary Dobson also notes that while marshlands in the 1th and early 14th centuries were home to large populations of people, by the 16th century, these areas became highly malarious. Dobson offers the possible explanation that the inning of the marshes that occurred during this period may have created ideal breeding habitats for Anopheles. mosquitoes and that "many coastal regions of Essex and Kent, once washed by the tides, found themselves inned from the sea and covered in pools of stagnant water."

Another very important change that occurred in western society was the rise of public health initiatives. Irrespective of the effectiveness of the development of new agricultural techniques and its associated factors, malaria remained a problem in Europe, although it was a diminished problem . It was not until nations began to invest in public health initiatives that malaria truly disappeared from the continent of Europe. The idea of 'public health' is relatively new (in a historical sense) and Dobson notes that "by the late eighteenth century, there was a move towards environmental improvements in many spheres and in diverse rural and urban localities, as a way of improving the healthiness of the people." Perhaps one of the first public health initiatives with regards to malaria was the making available of quinine to most people. Prior to this event, quinine due to its high cost was only available to the small percentage of the population that could afford it. In England for example, the cost of quinine "fell from about £1 per drachm in the 1840s to 8s 6d an ounce by 1875 and to less than 10d an ounce in the late nineteenth century". While the increase of use of quinine to treat malaria would not have affected the demographics of the disease, the widespread use of quinine would have certainly reduced the pathology and more debilitating effects of the disease. It can be said then that quinine was a factor in the amelioration of malaria in Europe that occurred from the late nineteenth and early twentieth centuries. Indeed prior to this reduction in cost of quinine, "an aggressive smuggling operation developed, reminiscent of that which is still present in the world today for cocaine." Incidentally, the effectiveness of quinine in treating 'marsh fevers and agues' is in fact proof that malaria existed in Europe since quinine is noted for its ability to treat malaria and malaria alone.

The most important type of public health initiatives vis-a-vis the disappearance of malaria from the continent of Europe however only became prevalent by the early twentieth century. It was during this time that 'anti-malarial' and malaria 'control' programs began to be developed. Paul Reiter is not incorrect when he observes that in Europe "it was not until the advent of DDT after World War II, that a concerted effort could be made to eradicate disease from the entire continent." For example, the nationwide campaign that Romania embarked upon to control the spread of malaria in 14, ended up being so successful that the program was converted into a malaria eradication program in 155 (see Table 1). The same kind ofanti-malarial campaign initiated in the Netherlands in the year 147 also resulted in a complete eradication of indigenous malaria (see Table ). Spain is another country that owes its malaria free status to the dedicated work of health authorities, among their accomplishments is "the establishment of 0 antimalaria dispensaries". Measures like this and the overall improvement of the quality of life of the citizens of Spain after the end of the Second World War caused the disappearance of malaria in Spain (see Table ). This is in contrast to the Netherlands and Romania, as both of these European nations had to employ direct antimalarial programs to remove endemic malaria from their midst.

It is important to note that even before malaria was expelled from the European continent, it had been on the decline in terms of both pathology and as a threat to public health in most European nations. In the 1860s the English Medical Officer of Health George Whitley surveyed the parishes in those localities that had previously suffered from the 'ague' and despite the fact that the 'ague still existed in the localities surveyed, it was noted that the 'ague' of 1864 was nowhere near as dangerous as it had been in the past. There are several possible causes of this pattern that have been noted.

One of the possible causes of the amelioration of the effects of malaria demonstrated in England was related to the fact that the frequency of mosquito bites might have been reduced due to the reduction of mosquito breeding habitat caused by the draining of salt marshes, the partitioning of humans and livestock into separate quarters and the overall decrease in population that occurred in rural regions as the Industrial Revolution drew increasing numbers of rural inhabitants to the cities to work in the factories that were developing there. All of these factors would have decreased the chances of Anopheles mosquitoes successfully transmitting the disease to new hosts and therefore the cycle of infection would have became harder to maintain.

It also has been noted that a reduction in the frequency of mosquitoes taking blood meals from the resident human population would have also decreased the odds of a patient suffering "repeated and successive attacks or a continuous invasion of mixed parasites, especially if a number of different species and strains of parasite had been formerly prevalent in the English marshes" and therefore the disease would be much less pathogenic to the host. The availability of quinine described above would have also contributed to this effect.

Another factor that may have influenced the seriousness of malaria (again as documented in England) was also related to the demographics of the more isolated malarious regions of England. By the beginning of the nineteenth century, the populations of certain marsh areas in England showed a decrease in the amount of newcomers and thereafter population numbers were maintained by positive birth rates, giving the area a newfound stability. This could be a significant development as patients of malaria often can develop partial immunity. In the absence of newcomers constantly bringing new strains of malaria, it might have been possible for the inhabitants of these areas to have developed a form of 'community immunity' which would have contributed greatly to the reduction of malaria as a serious disease in these areas.

A final factor that may have reduced the pathogenicity of malaria might be related to the fact that the people in Europe were becoming more healthy. European society was becoming aware of the need for clean drinking water, proper nutrition, better housing, improved hygiene and many other conditions necessary to maintain personal health. The improvement of diet and nutrition could have enabled sufferers of malaria to better cope with their infections. It should be noted however that there some debate on the issue of the effect of nutrition on the course of an infection of malaria.

In conclusion, while climate is an important factor in determining the geographic range and type of malaria that will be present in any given area, it is a fallacy to assume that just because malaria is best suited to tropical environments, it has always been strictly a tropical disease. This paper has demonstrated that malaria, far from being a stranger to the temperate shores of Europe, has instead been present in Europe from the times of antiquity. It has only been very recently that Europe has been declared malaria free. Furthermore, since the climate of Europe has been relatively constant for the past 00 years, it is obvious that other factors than the overall climate were at work reducing the effect and presence of malaria in Europe. This paper notes that socio-economic factors like changing agricultural techniques, demographics of populations and changing social attitudes towards issues like public health have had a far greater influence upon the epidemiology of malaria in Europe. The implications of this are far reaching. If the epidemiology of Europe has been influenced in a positive way by the changing of Western society, it is possible to infer that malaria might be less of medical problem and more of a social problem. If malaria is indeed a social problem, then the current efforts to curb malaria's depredations in much of the third world might be doomed to failure if the issues of poverty and underdevelopment in the nations of the third world are not attended to as well. The paper also serves to remind the reader that until very recently, nations in temperate regions had to contend with endemic malaria. Therefore climate is not a barrier to malaria and it should not be assumed that malaria can never again return to scourge nations that lie in the temperate parts of the earth.

Table 1. The number of cases of malaria in Romania during the period 148-177.

YearNumber of casesYear Number of cases

1488,181616

14,616418

1505,461651

1514,0816610

1510,4416716

15,10168

1540164

155817010

15641716

1571641717

158781717

1518417418

160817510

16181767

1617717

Note Since 16 all cases of malaria were either relapses of previous infections or accidentally induced by blood transfusion from infected donors or imported from abroad. The last case of indigenous malaria was recorded in 16.

Table . Cases of malaria in the Netherlands from 146 to178.

YearNumber of casesIndigenous cases YearNumber of cases

14615,0015,00164

1475,405,1701661

1484,5154,100164

146004016516

1508475166

1514101676

1516511684

1511516

15411801701

1551041716

1561117171

157100.17

1581041747

158117554

1600017676

16171177107

1640178108

16610

Note During the period 146-155 cases of indigenous and introduced malaria were classified separately. For the period 156-16 these cases are included in the totals; the bulk of the latter is composed of imported cases. From 16 onwards all cases of malaria were imported from abroad.

Table . Morbidity and mortality from malaria in Spain (16-178).

Year Number of cases notifiedNumber of deathsYearNumber of cases notifiedNumber of deaths

164,757168158610

1761,54171501

1881,45816080

185,5068161150

14010,487561680

1415,51,781650

1476,7741,78116410

1446,751,0716510

14440,6516660

145105,650116710

146,557516840

14786,764188160

14864,81641700

144,87084171780

15018,7071710

15114,54561740

15,4754817411

155,817500

154,7761760

155,006177570

1561,08161780

15746414

Note The last indigenous cases of malaria in Spain were reported in 16. Since then all cases were imported from overseas, with the exception of 171 when over 54 cases of P. vivax malaria occurred as a result of accidental outbreak of transfusion malaria from a blood bank, where overseas donors were involved.

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