My Malaria

May 2, 2004
Outside Magazine
Outside magazine, March 1994

My Malaria

Adventures in delirium. Or, why I'm on a steak and gin-and-tonic diet, for my health
By Tim Cahill

I was eating breakfast on the terrace of a small restaurant near Santa Fe, New Mexico, when the odor washed over our party like a fetid cloud. If stench could have a color, this one would have been dark brown, thick as clay, and dense enough to cast a shadow. No one at the table sought to cast accusatory glances, because the odor was overwhelming and beyond the capacity of any one human being to produce. It seemed to have erupted out of the ground, rolling over our table from an open manhole where several men were gathered. The men were dragging something up out of the hole with a small crane mounted on a local utilities truck. A hint of yellow appeared. Whatever the thing was, it was round and about the size of a volleyball or--could it be?--a man's head.

"Oh God, no," someone said as the object came into full view. It was, in fact, a human body, still as death, and dripping raw sewage. There was a profound silence on the terrace.

The dead man was clad in a yellow rain suit. The workmen seemed unconcerned. Did they pull bodies out of sewers every day in New Mexico? What the hell kind of place was this?

And then, feebly it seemed, the body moved. An arm jutted out stiffly. The man was set down on his feet on the pavement. He passed a few words with the workmen, then lurched off toward the truck, still dripping sewage.

"I suppose," Larry Burke said, "they sent that poor guy down there to scout out some obstruction."

"Or clear it," I said.

We took our plates out of the rolling stench and into the restaurant proper. Larry Burke, who is the publisher of this magazine, and I were meeting to catch up on each other's life and to discuss my work, which encompasses travel to remote destinations, contact with interesting people, and a reasonably liberal expense account. No complaints on my end: I like what I do for a living. To some extent, it must show. That very week, in fact, I had been contacted by a daytime television talk show: Would I appear on a program, the focus of which would be "people who love their jobs"? The idea made for some queasiness. What was I, just one more societal anomaly, like lesbian nuns or men who wear diapers?

The thought also carried a pinprick of irritation. The truth is, there are times when I'm at least as miserable as anyone else. There is, for instance, this snotty little work-related disease that keeps popping up.

I might even have gotten around to mentioning the problem to Larry during that breakfast. But they dragged the guy up out of the manhole, and any whining I might have done to distinguish myself from the average daytime talk-show curiosity turned immediately to sewage. The man in the yellow slicker was the embodiment of a single undeniable fact: There are people in the world who have worse jobs than mine. Lots worse.

If various sewer-related topics hadn't dominated the rest of the breakfast conversation, I might have told Larry that I'm not really fit for the talk shows because I suffer from an ancient disease, a recurrent fever out of time. First described by Hippocrates in the fifth century B.C., it's now called malaria--from the Italian, meaning "bad air"--and considered on a worldwide basis, it's probably the most common of all diseases.

Malaria is caused by certain parasitic protozoa of the genus Plasmodium and is spread by female anopheline mosquitoes. (Males are blameless vegetarians, living entirely on plant juices). The female feeds on blood. If her human victim is infected, she ingests malarial parasites along with her dollop of blood. The sexual forms of the Plasmodium parasite, gametocytes, mate in the female's gut, and a fertilized sex cell forms, which encysts in the wall of the stomach. One to three weeks later, the cyst bursts, spewing out what one of my reference books describes as "a large number of young asexual parasites," which sounds to me like your basic disco inferno for the nineties.

These parasites, called sporozoites, work their way into the female mosquito's salivary glands and are thus passed on to the next human she bites. The sporozoites settle in the victim's liver, where they multiply, eventually spilling into the bloodstream in the form of merozoites, which enter the red blood cells and reproduce asexually until the blood cells burst. The newly formed merozoites migrate to intact red blood cells, where they once again multiply, destroy the cell, and move on. It's one big game of parasitic Pac Man, played for blood.

Eventually some sexual forms of the parasite, the gametocytes, are produced. They do not mate in the human body. If the victim is bitten again, however, the gametocytes are ingested by the mosquito, a new sex cell forms in the insect's stomach, the young sexual parasites have a party, and so it goes. Bad air.

The air in the swamplands of Irian Jaya was a miasma, muggy and thick. It was, in fact, like living inside an open wound. And there were lots of mosquitoes. They were, I now know for a fact, anopheles mosquitoes.

My malarial sufferings, the books tell me, are fairly typical. Here's the way it started for me. Six weeks after I got home from the swamps of Irian Jaya, I began feeling stiff. My joints ached. Someone asked me why I was limping. I hadn't realized that I was. I was working on a deadline, writing, in fact, about the swamps of Irian Jaya and drinking entirely too much coffee. Was that why my urine was brown, like muddy water? Coffee, in my experience, tends to have the opposite effect.

I didn't realize for a few days that I was pissing away broken red blood cells. I felt woozy and tried to focus my attention on the problem at hand, which was my story about the swamps and the people who lived there. The tribe I had visited lived on platform houses set 50 feet up in the trees, well above the choking clouds of mosquitoes that owned the forest floor. The men generally kept to the trees, but the women climbed down daily to collect food, firewood, and water. All of the women carried circular scars up and down their arms. Burning the arms with coals, I learned, was thought to be a cure for the "shivering sickness," which seemed to be epidemic.

I sat for hours below one of the tree houses while two of our party parlayed with the men above. Waiting below during the lengthy negotiations was hateful. Six weeks later, with aching hands, I wrote about the experience: "Mosquitoes attacked those of us on the ground in thick clouds. They were very naughty and probably malarial."

In retrospect, I see now that only a very sick man could write a sentence like that last one. The next afternoon, I began shivering uncontrollably. It was 90 degrees outside, a brilliant Montana summer day, and my teeth were chattering. I'd seen people all over the tropical world in this initial stage of a malaria attack. Now I had it.

The chills last about an hour and are followed by what is called the febrile stage, which starts with a feeling of intense heat, a headache, and a very high temperature. Since my initial chills are fairly severe, I shake until I'm exhausted and generally fall asleep just as the fever hits. The dreams are exceptionally vivid. Sometimes they are experienced in a vague waking state and can be considered a form of delirium.

The febrile stage goes on for a couple of hours and is followed by a period of intense, sheet-soaking sweats accompanied by vestiges of headache and a feeling that the synovial fluid around every joint has been replaced by a mixture of sawdust and ground glass.

It's all over in about five hours.

A day or so later, you get to go through the whole thing again. Sometimes the interval between attacks may be longer: two, three, or four days. It all depends on the rate at which the asexual parasites are multiplying and bursting out of the red blood cells.

I was on a precise 24-hour cycle. "Sorry," I'd tell my friends, "It's four o'clock. I have to go have malaria now. But hey, let's eat at ten."

There are four species of Plasmodium that cause malaria. P. vivax is the most common; P. falciparum is the most severe and the most frequently fatal.

From 1980 to 1988, 1,534 cases of infection with P. falciparum among U.S. civilians were reported to the Centers for Disease Control and Prevention. Eighty percent of the cases were acquired in tropical Africa, with the rest fairly evenly spread out among Asia, the Caribbean, Central and South America, and other parts of the world. Of the 37 fatal cases, 27 were acquired in Africa. P. falciparum infection can, with vicious suddenness, cause liver, kidney, or respiratory failure. It may block the small blood vessels in the brain and cause coma.

Photographer Chris Rainier once told me a haunting and terrifying story about just how quickly P. falciparum can kill.

Several years ago, Chris was traveling in the Sudan with a group of doctors from the World Health Organization. They were inoculating people in remote villages. One day, at 10:30 in the morning, a volunteer nurse began shivering in the heat. She lost consciousness two hours later. By 4:30 that afternoon, she was dead.

A week or so later, Chris came down with the classic symptoms: aching bones, brown urine, chills, chattering teeth, uncontrollable shivering. The doctors told him they'd do everything they possibly could to save his life. They also suggested that he might want to write a last letter home. He had, they thought, perhaps an hour of consciousness left.

I asked Chris, who had a very bad go of it for a few weeks, whether he actually wrote the letter. He said he did. He couldn't remember it exactly--he wasn't feeling so hot and felt a bit distracted at the time--but it read something like "Dear Mom and Dad, I was doing what I wanted to do. I love you both. Please take care of my dog."

This compares--not unfavorably, I think--with John Keats's last letter, written to Charles Armitage Brown on November 30, 1820: "I can scarcely bid you good-bye, even in a letter. I always made an awkward bow." Keats was dying of tuberculosis and had a lot more time than Chris Rainier. He was also one of the greatest poets in the English language and didn't, apparently, have a dog.

When my shivering started on that bright summer afternoon, I didn't know what variety of malaria I'd contracted and thought about writing the final letter.

What does a person say? How do you explain your life in couple of pages?

For a while, I occupied myself with the question of who should get copies of the letter. The list should be fairly inclusive, like, say, wedding invitations. You don't want to leave anyone out. Parents, lover, best friends, sure. Ex-wives, yeah. Business associates, OK. I had worked back through my life to a beloved high-school swimming coach when the febrile stage hit and I fell completely and irredeemably asleep.

The fever dream was a bad one, full of anxiety. I was, for reasons that seemed perfectly obvious at the time, forced to occupy someone else's body. Who was this guy? He seemed to be crouched in a tower, looking down at the lawns and walkways of a busy college campus. He was holding a rifle. People were running in panic, and faint screams drifted up to the tower. Had this yo-yo shot anyone yet? I could see a few broken windows in a building across the way, but there were no bodies down. A SWAT team was making its way across the lawn, toward the tower.

My problem, as I saw it, was to explain to the police that I was not really this wacko with the rifle. I was a nice, normal guy who happened, through no fault of his own, to be temporarily inhabiting the body of a deranged sniper. "Sure," I imagined the SWAT team leader saying just before they opened up with the shotguns, "that's what all you deranged snipers say."

The dream insisted that I come up with some more-satisfactory explanation for my presence in that particular body. What? My mind skidded off in several directions at once. I could hear heavy footsteps pounding up the stairs. There seemed to be no way to adequately account for the person I truly was.

This dream, I think, mirrored my anxiety about the last letter. If I could just explain myself properly, maybe I wouldn't have to die.

Since then, I've often wondered whether, in some larger sense, that's what we all think. We produce art or music or literature or philosophy or children; we make laws or medicine or history; we become saints or outlaws in our lifelong scramble to create some living context. This, we need to say, is who I truly am. It's our one shot at immortality.

The blood tests came back positive. "It's malaria," my doctor said.

"What kind?"


Common malaria. Not something fairly exotic, like P. ovale or P. malariae. Not the deadly P. falciparum, either. People I know who've survived a falciparum infection have suffered badly. During lucid periods, several thought they were going to die. By contrast, my vivax is pretty mild: a walk in the park.

But unlike my falciparum-suffering friends--who tend to go through a single frightening incident--the vivax I have recurs at more or less regular intervals. The parasite, like many microorganisms, clings stubbornly to life. Vivax is the prevalent form of the disease precisely because it withstands therapy and can become chronic.

My doctor, who doesn't have much occasion to treat malaria in Montana, consulted with a tropical medicine expert, and together they worked out a treatment program. There was no way to know for sure whether the various pills would, in fact, kill all those merozoites and sporozoites and gametocytes smooching around in my blood. And they didn't.

About six months after my first episode, I was giving a series of readings at the University of Montana, about 250 miles from my home. The malaria started shaking me around about four the first afternoon. Then came the required five hours of misery, but the next day, precisely at four, I gave my reading and felt just fine. Hey, no recurrence! A day later, I was driving home, over icy roads and through a minor blizzard, when my hands began shaking on the steering wheel. It seemed I was on a 48-hour cycle this time. My friend Linnea took over the wheel and I sat twitching in the passenger seat. My pills, which would knock out the infection within 24 hours, were at home. Why did I leave them at home? Apparently, I was moaning with each exhalation of breath.

"Music bother you?" Linnea asked.


"Because, I'm sorry, the moaning's driving me nuts."

And so we listened to music at top volume, and I never did pass out during the febrile stage but was able, in a half-waking state, to harness the fever dreams, which I played across the windshield as the wipers swept the snow away. I was in a deep green forest. Sunlight fell in shafts through alien flowers that grew everywhere on strange, otherworldly trees. I was not precisely human and seemed to be some sort of combination of butterfly and bird. It was strange to see this peculiar world in three dimensions, and I wondered about that until I realized that I was soaring through a jungle as painted by Henri Rousseau, the jungle of The Sleeping Gypsy.

It was an hour and a half of exhilarating delirium.

My friend the photographer Nick Nichols once suffered a relapse of malaria in New York. He was staying at an upscale hotel, editing pictures he'd taken in Africa for a magazine story, when his teeth started chattering. By the time the house doctor arrived, Nick had sweat through the sheets on his bed. He had wrung them out and hung them over the shower curtain. So there he was, lying on a bare mattress, sweating profusely, and looking like a junkie in need of a fix.

" What seems to be the trouble?" the doctor asked.

"I have malaria," Nick said.

The doctor began asking him a series of irritating questions. Were Nick's stools black and tarry? Were people following him? Did he hear voices when there was no one there?

"I'm not crazy, you asshole," Nick screamed. "I have malaria."

Health professionals in America often have little experience treating the disease, which is always in a dynamic state of change. Generally, when traveling to malarial areas, it's wise to begin taking preventive drugs about two weeks before departure and to continue the regimen for six more weeks upon return. I can testify, however, to the fact that this is not always 100 percent effective. Plasmodium parasites are persistent and quickly become immune to last year's preventive or therapeutic drug of choice. One useful source of up-to-date information is the Centers for Disease Control and Prevention in Atlanta, which maintains an international travelers' hot line (404-332-4559) with information about malarial areas and current treatments.

As far as identification goes, I've been told that anopheles mosquitoes sit at a slant on a flat surface. This may be so, but I've never been able to arrange the necessary flat surface in conjunction with a stationary mosquito. Identifying mosquitoes in this way is like trying to sprinkle salt on the tail of bird. I do know that anopheles mosquitoes are never found at altitude. One source tells me they do not occur above 3,000 feet.

That bit of anopheles esoterica was of use to me several years ago when I was searching for the ruins of a pre-Inca society in the eastern foothills of the Peruvian Andes. No use looking in the fertile river valleys: The stone huts and great forts of the Chachapoyas people were perched on cloud-shrouded peaks at 10,000 feet. The Chachapoyas laboriously terraced the steep mountain slopes in order to grow crops and built stone catchments for rain, their only source of water. They lived this hard, high-altitude life because the river bottoms were rife with malaria.

The disease might have arrived in the Americas with Columbus. A few hundred years later, Indians in the Amazon were successfully treating malaria with bark of the cinchona tree. This is an interesting and persuasive argument for biological diversity: As we decimate the world's forests, do we also lose the potential cure for various diseases, both those that are killing people today and those, perhaps presently unknown, that will kill in the future?

As for me, well, I still search for ancient ruins up high. I take my prescribed pills at the proper time. On my own, I've begun eating huge bloody steaks because I think they replenish my red blood cells. I also drink the distilled essence of cinchona bark, which can be found in tonic or quinine water. Massive doses of quinine, however, may cause cinchonism, a syndrome whose symptoms include blindness and deafness. It is safer and healthier to flavor a few ounces of quinine with a shot or so of gin. The wise malaria sufferer wakes up in the morning, lying on the couch, with the overhead light blazing away. He has a headache, the events of the previous evening may not be in satisfactory focus, but he can see. He can hear. "Thank God," he says to himself, "that I thought to mix my quinine with gin."

It's not a bad life, really. I'm the only person I know who's on the steak and gin-and-tonic diet, for his health.

The day after that breakfast on the terrace near Santa Fe, malaria knocked me down again. I had the pills with me, and since I was going to have to go through this episode anyway, I found that I was actually looking forward to the fever dreams. So there I was, shivering in front of the motel television while some twitching dysfunctional tried to explain his deplorable existence to America through Oprah. "This is who I am," he meant to say, his one and only shot at immortality.

It could have been me, I suppose, telling America why I loved my job. That particular day, I would have been acceptably pathetic and just right for daytime TV: a thoroughly broken-looking man, shifting in pain in his chair, shaking badly, soaked through with sweat, babbling incomprehensibly about nifty perks--high-altitude ruins and gin-and-tonic and great slabs of bloody red meat.

"You got malaria on the job," the host might ask, "and you still love your work?" And in my waking fever-dream, projected transparently across a sea of concerned faces, I would see a body dragged out of a stinking sewer, and I expect I'd say, "There are worse jobs than mine. Lots worse."

Tim Cahill is Outside's editor-at-large. His latest book is Pecked to Death by Ducks (Random House).

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