Waiting for a miracle
Jim Crace – author of Quarantine – goes on the front line of disease control in Cambodia
Tourism in Cambodia is booming. But behind the veneer of success, life is fraught with danger – Aids and malaria are rife, and the countryside is littered with landmines.
The volunteer farmers who bare their skin throughout the night and offer their blood to the mosquitoes of Pailin are taking grave risks for a good reason. Armed with a flashlight, some cotton wool and a test tube each, and with their trouser legs rolled up, it is their low-tech duty to wait until an insect, attracted mostly by the carbon dioxide in perspiration or breath, alights on their skin, and then to capture it for the laboratories of Phnom Penh, where its disease-bearing parasite levels can be assessed.
In this remotest district of Cambodia, tight up against the Thai border on the northern slopes of the Cardamom mountains where the Khmer Rouge fought their final battles, and where some of their cadres are now senior figures in the administration, the mosquitoes are among the world’s most deadly. A single bite and any of these eight human baits, working in four-hour shifts, could become the bone-aching, haemorrhaging victims of dengue fever, which is at its most virulent during this season of monsoons and which, though not normally lethal except for children and the very old, is incurable. According to Richard Veerman, my Médecins Sans Frontières (MSF) host and its head of mission in Cambodia, who has himself only just recovered from the fever, “You can do nothing about it but sit out the pain and hope not to die.”
But it is not dengue that should worry me most, when I sit down on the boggy ground in the tiny village of Pang Rolim to join the volunteers and bare my own leg to the mosquitoes. Nor is it the deadly russell’s vipers or the cobras that are common in the soya-bean fields behind us. Nor is it even the undetected and undetonated landmines that, according to a recent Unicef report, make these farmlands “one of the most dangerous places in the world”. What should have kept our legs covered is the knowledge that the anopheles mosquitoes of Pailin or, more specifically, the single-cell Plasmodium falciparum malaria parasites that live in them and us, were the first in the world to develop (through over-prescribing and incomplete dosing) a resistance to chloroquine. This is the drug which for decades has been humankind’s main defence against malaria. I have suffered from malaria before, in Sudan, and I got through with little more than a debilitating fever, but that was the less deadly P vivax strain, which has yet to develop resistance to drugs.
Yet my fellow volunteers and I are not being foolhardy. We can be confident that whatever the parasite-load of the vectors filling their abdomens with our blood, we are unlikely to contribute to the worldwide toll of 2.7m malaria deaths each year (out of the at least 350m almost exclusively poor people who, according to a UN report of May 2005, sicken with the disease). In this fortunate village at least, there is a new and readily available treatment for P falciparum, a cocktail based on artemisinin, an extract from sweet wormwood. But it has to be administered swiftly. All the locals understand, from the too recent and bitter experience of neighbours, that to contract this strain of malaria in Pailin and leave it to its own devices is to invite a rapid and painful death. After a week or more, we could expect fever, muscle pains and headaches, explains Bart Janssens, MSF’s medical co-ordinator. For any victims beyond the reach of artemisinin, however, diarrhoea, nausea and anaemia might develop. And finally, in a third to a half of all cases, there would be “severe complications”, including brain damage, multiple organ failure and coma. “You could be dead in 10 days,” he warns.
Our job that night, under the scrutiny of an entomologist, Dr Tho Sochantha, from the Centre for Malariology, is to help verify what the rapidly falling P falciparum prevalence and death toll has been suggesting: that MSF’s volunteer-based, rapid-treatment programme for malaria in these forest-edge villages, where conditions are perfect for breeding mosquitoes, is “breaking the pathways of transmission” between female insects, parasites and humans.
My own contribution to the insect survey is only modest. I seem at first to be more attractive to ants than to mosquitoes. But finally, in the pitch-blackness, I learn to recognise the weightless, fussy probing of anopheles on my shins, and I begin to fill a test tube with my captives.
At the end of my shift, Dr Sochantha holds my tally up to his magnifier and, much to the delight of a crowd that has abandoned a blaring, battery-powered television set to watch a European make a meal of himself, declares my specimens to be “from a vector that normally prefers to feed on cows”. He would be happy to offer me a trapper’s job at any time, though. “You are a good hunter,” he says. “Their abdomens are not bloated. You have captured them before they could feed.” What I do not mention is that, though my leg has not been pierced, the back of my neck is already itchy and lumpy from a dozen uninterrupted bites.