Quinine, the alkaline derived from the bark of the quina-quina tree, would prove the most effective treatment for malarial fever and infection in human history. In the decades after the bark of the tree was exported to Europe, every state with imperialist aspirations wanted access to quinine. The Spanish Crown, recognizing quina bark for its power and lucrativeness, monopolized the harvest and export of the medicament. By the beginning of the 19th century, the imperialist aspirations of Europeans required an effective malaria treatment. The quest for quinine led to a robust smuggling ring empowered by the Age of Revolutions, Italian social welfare, and the invention of the British Empire’s cocktail of choice. Quinine’s role in reshaping the world is immeasurable… but we’re going to give it the old college try!
Transcript for The Sacred Bark: A History of Quinine
Researched and written by Averill Earls, PhD
Recorded by Averill Earls and Marissa C. Rhodes, PhD
Edited by Averill Earls
Averill: Malaria is as persistent as it is old. Scientists found evidence of mosquito-carried malarial parasites preserved in amber from over 30 million years ago. From our beginnings on the African continent, humans have been afflicted by and attempted to treat malarial infection. It’s only in the last 100 years that we’ve made any kind of significant headway, with synthetic prophylactics and treatments. Today, 2.9% of the world population has malaria. According to the 2019 World Health Organization (WHO) malaria report, there were 228 million cases in 2018, which was down from 251 million in 2010. In 2018, there were 405,000 deaths from malaria globally, with 67% of those deaths children under the age of 5. These are devastating figures, as is every preventable death, but are also significantly lower than they were 20 years ago. In the 2005 report, the WHO estimated that there were 350-500 new cases every year, and that at least 1 million people in Africa alone died annually from malaria.
Marissa: For centuries the wealthy of malarial cities like Rome fled to cooler climes in the malaria season, and the poor suffered the fevers and weakness of the parasitic infection. Doctors and healers prescribed herbal remedies like artemisia and belladonna, or ordered blood letting, trepanning, or even amputations. In regions like sub-Saharan Africa, where the parasite thrived year-round, members of the population developed sickle cell anemia, a red blood cell mutation that protected the carrier from malaria, while creating its own set of health challenges. The devastation of malaria kept Europeans armies out of the interior of Africa for decades, as the Dutch, Portuguese, and English had no immunities to the parasite and its debilitating fevers. But when Italian priests accompanied Spanish invaders in central America, bringing with them the malarial mosquitoes and introducing the disease to the Amazonian basin and Andean mountains, the Inca introduced the Europeans to a game-changing treatment: the powdered bark of a Peruvian tree, which has been called quina-quina, cascarilla, or most commonly today, Cinchona.
Averill: Quinine, the alkaline derived from the bark of the cinchona tree, would prove the most effective treatment for malarial fever and infection in human history. In the decades after the bark of the tree was exported to Europe, every state with imperialist aspirations wanted access to quinine. The Spanish Crown, recognizing quina bark for its power and lucrativeness, monopolized the harvest and export of the medicament. But while their mismanagement of silver mining flooded the market and devalued their fortunes, the Spanish overharvested the quina supply, and made the race for a new supply all the more important. By the beginning of the 19th century, the imperialist aspirations of Europeans required an effective malaria treatment. The quest for quinine led to a robust smuggling ring empowered by the Age of Revolutions, significant advances in the synthesis of organic compounds, the start of homeopathy, and the invention of the British Empire’s cocktail of choice. Quinine’s role in reshaping the world is almost immeasurable.
I’m Averill Earls
And I’m Marissa Rhodes
And we are your historians for this episode of Dig.
Marissa: Before we regale you with stories of drugs and disease, we have some very special people to thank. Our patreon supporters keep the lights on and the microphones recording, and we are grateful for each and every one of you. We want to give a special shoutout to our mega-donors, our Auger and Excavator level patrons: Maddie, Denise, Colin, Edward, Susan, Christopher, Peggy, Maggie, Danielle, and Iris! Your generosity knows no bounds, and we are honored that you choose us to support. Listener, if you are not yet a patron of this show, it’s easy: just go to patreon.com/digpodcast to learn more
Averill: Malaria is caused by several species of the parasite Plasmodium. The parasites live in the salivary glands of mosquitoes, which then move into the bloodstream when a mosquito bites another organism. There are many strains of Plasmodium, including strains that will attack rodents, birds, reptiles, and, of course, primates, including non-human primates. There are also several strains that will attack humans, some worse than others. One, Plasmodium falciparum, can be quickly fatal, because it can produce blood clots in the brain. The most common symptom of malarial infection is intermittent fevers. The fevers come and go because they are associated with the lifecycle of the Plasmodium, which sets up shop in the liver, and as it releases its offspring into the bloodstream, the offspring enter, feed on, and destroy red blood cells. If the host recovers from the malarial fever, they will feel anemic – because of the loss of red blood cells – and listless. Without treatment, a host will continue to experience intermittent fever until so weakened that their organs fail and they die. The body, as our listening medical professionals know, needs its red blood cells to carry oxygen throughout the body. Without oxygen, we die.
Get this picture: CDC
Marissa: Well before the disease’s true source was understood, the Romans called the Plasmodium infection “malaria,” old Italian for “bad air.” Medieval Italians, following the logic of the miasma theory of disease, believed that malaria originated in the smell that emanated from the Compagna and city’s swamps. Malaria existed seasonally in places like the Mediterranean; in some regions of Eurasia and Africa–the Congo, India, and other humid climes–malaria was a constant. The parasitic origins of the disease made it very hard to treat, and victims of the worst strains of malaria died in droves. Some historians credit a particularly harsh malarial summer as the cause of the fall of the Roman empire.
Averill: Conversely, malaria was unknown in central and South America until the European invaders arrived. In addition to bloodsucking stowaways in the European ships, any conquistadors who were infected with the Plasmodium parasite could pass it to the native species of mosquitoes inhabiting the South American lowlands.
Marissa: The Quechua-speaking people of the Andean highlands had a very effective treatment for fevers: the quina-quina tree, which is generally translated as “bark of barks” in Quechua. Their healers, curanderos, collected the bark, dried it, and then crushed it into a powder to mix with water and ingest. Though they’d never encountered malarial fever before, the Quechua healers used the quina bark to treat those afflicted, and it proved just as effective.
Averill: (Side note: yes, these are the same curanderos that we talked about in my episode on cunning folk! Healing arts in south America had spiritual/magical properties, just as they did in early modern/ancient/etc Europe. When the European missionaries were traipsing around the Andean highlands in search of souls to save, they saw curandero knowledge and practice as the work of the devil, even as they recorded and benefitted from curandero knowledge and practice.)
Marissa: While the curanderos had been using quina bark to treat fevers for decades, perhaps centuries before the Europeans invaded, they also had a range of fever-reducer herbs at their disposal. Historian Matthew Crawford suggests that it was the Andean medical-cosmological precursors that had the curanderos applying quina bark to malarial fever shortly after the disease began afflicting indigenous peoples. We don’t know when exactly malaria made its way to the Andean region, though it would most likely to have been in the first decade or so after Francisco Pizzarro murdered Atahuallpa, the last free-standing South American emperor, in 1533. Though the curanderos may have dabbled in trial and error medical experimentation to find a cure for malarial fever, Crawford argues that their medical cosmology would have steered them toward quina bark from the outset. According to Andean medical lore, organized around the hot-cold dichotomy, herbs harvested from cold regions were considered “hot,” and vice versa. Quina bark was harvested from the Loja region, which was hot, and so the bark was cold – the perfect remedy for fever.
Averill: Some of the first Europeans to take note of the indigenous medicament were Jesuits priests, who’d been dispatched to the “New World” to collect souls and knowledge for the Catholic Church. The Society of Jesus, or Jesuits, is a religious order of Catholic priests that originated in Spain but had, by the 17th century, become a powerful tool for Roman Catholic power and reach around the world. Members of the order arrived in South America as early as 1559, and immediately went to work building schools and missions. As in Catholic regions of Europe, Jesuits served as advisors and teachers of the colonial elite, and were able to move freely through the colonial world. Jesuit priests, including Bernabé de Cobo and Cardinal Juan de Lugo, are credited with introducing the bark to Europe around 1640. Because of their role in getting the bark into the hands of European botanists and healers, quina bark was known widely by a range of Vatican-inspired nicknames, including the Sacred Bark, Jesuits bark, Cardinal’s powder, and Popish powder.
Marissa: Though the earliest accounts of the bark, like that of Nicholas Monardes, credited the Andean healers with its discovery and use, that credit would be worn down by the decades and association with the Vatican. Though in the last 10 years the narrative of quinine’s “discovery” is being shifted back to indigenous medical knowledge – recent articles in Slate and the history section of Erasmus Bond, a tonic company, both acknowledge the Andean’s use of the bark to treat fevers – there are also still medical journals that discuss cinchona’s “discovery” in the 17th century, centering the narrative of quinine firmly as a Euro-centric miracle cure.
Averill: European taxonomer Carl Linnaeus helped along this myth by naming the tree Cinchona, after a European Countess, who was allegedly treated with the quina bark in 1638 when she came down with malarial fever. Several accounts, including that of the British explorer Clements Markham (whom we will return to), reported that it was the Countess who first brought the quantity of bark to Spain in 1640. According to Markham, writing in 1862:
While the Countess Ana was suffering from fever in 1638, in her sixty-third year, the Corregidor of Loxa, Don Juan Lopez de Canizares, sent a parcel of powdered quinquina bark to her physician, Juan de Vega, who was also captain of the armoury, assuring him that it was a sovereign and never-failing remedy for “tertiana.” It was administered to the Countess and effected a complete cure….The Count of Chinchon returned to Spain in 1640, and his Countess, bringing with her a quantity of the healing bark, was thus the first person to introduce this invaluable medicine into Europe. Hence it was sometimes called Countess’s bark, and Countess’s powder. Her physician, Juan de Vega, sold it at Seville for one hundred reals the pound. In memory of this great service Linnæus named the genus which yields it Chinchona, and afterwards the lady Ana’s name was still further immortalized in the great family of Chinchonaceæ. … By modern writers the first h has usually been dropped, and the word is now almost invariably, but most erroneously, spelt Cinchona.
After the cure of the Countess of Chinchon, the Jesuits were the great promoters of the introduction of bark into Europe. In 1639, as the last act of his viceroyalty, her husband did good service to the cause of geographical discovery, by causing the expedition under the Portuguese Texeira to proceed from Quito to the mouth of the Amazons, accompanied by the Jesuit Acuña, who wrote a most valuable account of the voyage.
Marissa: Through brutal conquest, the Spanish Crown controlled most of South America by 1600. It was only through local knowledge that the secrets of the fever tree were accessible. The useful varieties of the tree were native to the Andean region of the former Incan empire, which the Spanish conquered in 1534. The Quechua-speaking people knew where the trees grew, how to identify them, how to harvest the bark, and how to use it as a medicine..
Averill: As early as 1571, Spanish physician Nicholas Monardes discussed an Indian remedy, derived from a tree bark in the Loja region, in his medical treatise. Historians agree that this was quina bark. Crawford also points out that the Andean medical theory – a system that involved balance between hot and cold in the body, as well as in state and divine matters – would have been particularly familiar to the Europeans, who operated within the Galenic humoral model of medicine and disease. This may explain why Europeans were comfortable adopting so many Andean and other indigenous herbal remedies so quickly. However, because the powdered bark had a particularly bitter flavor, under the European medical cosmology, quina bark would have been classified as “hot”, making it inappropriate for treatment of a hot disease like fever. Fortunately for the Europeans, Crawford notes, therapeutic use and success outweighed theoretical incompatibility.
Marissa: The bark was globalized by the end of the 17th century, and became one of the “most valuable and widely used medicaments in the Atlantic” because of its recognition as the best treatment for malarial fevers. It was officially introduced into the London Pharmacopoeia in 1677, and by 1681 it was universally accepted as an antimalarial substance. Stefanie Gänger notes that even as both the bark and the disease were known by many different names across Eurasia, all botanists and medical practitioners agreed that the bark of the quina-quina tree was the–singular–treatment for malaria. It was extremely valuable because of both its efficacy and rarity. Ganger describes its ubiquity most eloquently:
Averill: “Bittersweet ‘febrifugal lemonades’, and bottled wines of the bark sat on the shelves of Lima apothecaries, the counters of Cantonese market stands, and in the medicine chests of Luanda hospital orderlies. They were routinely concocted, and administered at the bedsides, by Moroccan court physicians, French housewives, and (en)slaved healers alike, and they accompanied, tucked into their pouches, Dutch sailors to febrile environs, Peruvian soldiers to the battlefield, and North American settlers westward. Scottish physicians, creole botanists, and French writers alike were unanimous not only in according the bark ‘singularity,’ and ‘the first place among the most effective remedies,’ but also in holding it to be ‘more generally useful to mankind than any in the materia medica.”
Marissa: Through the end of the 18th century, it still only grew in the Andean region, in New Granada and Peru, and thus remained under the control of the Spanish crown. But the Spanish monopoly and methods of extraction were inefficient, and couldn’t keep up with the demand.
Averill: In 1751 the Spanish Crown established royal reserves at Loja to supply the Royal Pharmacy in Madrid with regular, annual shipments of quina bark. Spanish King Ferdinand VI’s representatives declared the bark “an object worthy of interest, curiosity, and attention.” But by the time the Crown decided to establish their monopoly, the bark was already widely commoditized. As suggested by the lateness of the Crown’s involvement – after all, the bark was a widely known treatment for malaria by the mid-18th century – it was the pre-existing market for cinchona bark that attracted the Crown to it, but they came to the cinchona bark game late. As Crawford notes, the 18th century presented a range of challenges that undermined the Crown’s effort to monopolize the bark. Annual harvesting for the Crown took a toll on the quina supply, and the quina quina trees became harder to find. The potency of the bark degraded in the time between harvesting and use; for the long sea voyage across the Atlantic to Spain, it lost its “medical efficacy.” The merchants who transported the bark mixed it with other, non cinchona-tree bark to inflate their profits, but thus defrauded their European customers. The crown depended on indigenous peoples for the knowledge necessary to differentiate the different varieties of Cinchona tree, as different trees produced different potencies of bark. In typical conquistador form, the Spanish relied on the indigenous medical cosmology even as their missionaries associated the work of the curanderos as idolatry and Devil Worship, and attempted to eradicate indigenous religious beliefs.
Marissa: And significantly, by 1780, the Spanish-owned commercial monopoly and overharvesting led to the beginning of the slow extinction of the natural cinchona forests. Demand for the bark peaked in the first half of the 18th century, and though the harvesting season was short (summer only), and labor intensive, the natural supply was mostly able to keep up. After the Spanish Crown made its royal order, and ramped up harvesting 22 times that of the first quarter of the century, the natural supply was quickly put in danger of complete depletion.
Averill: After 1717, Cadiz was only the port city granted rights to trade with the Americas by the Crown in Spain. Between 1718-1728, the annual average of Cinchona bark imported at Cadiz was 14,000 pounds. Between 1752-58, the annual average was nearly 318,000 pounds. By the end of the 18th century, the Crown had to significantly scale back its harvesting endeavors, in part because of the strain on the local ecology – but mostly because of the impending doom of the Spanish empire.
Marissa: By the 19th century, the Spanish empire was already crumbling. Revolutionaries and smugglers alike took advantage of the turmoil created by Napoleon’s invasion of the Iberian peninsula in 1808. According to Crawford, “Foreign merchants encouraged bark collectors to trade by claiming that ‘there is no King and there is no Spain,’ while telling other groups of bark collectors that the Crown had ‘opened the harvesting of the bark to all those that wanted to extract it.’” British travelers like William Stevenson and Clements Markham asserted that the Spanish had harvested the cinchona to near extinction, and propped that narrative up as justification for intervention.
Averill: Historians contend that reports of cinchona extinction were hyperbole. In 1860, the then-independent Andean countries exported nearly 2 million pounds of bark. Rather than depletion of the supply, the Andean harvesters just had to shift to cultivation rather than wild foraging. Up through the late 18th century, the Spanish Crown representatives still relied primarily on trees in the wild, which were hard to find (without indigenous knowledge), and required bark collectors to wait years between harvests for the bark to grow back. By the 19th century, that model had shifted to widespread cultivation. Still, other Europeans — especially the British, Dutch, and French, who relied on quinine for their imperial aspirations — claimed the forests were going extinct to justify their smuggling operations.
Marissa: In 1981, historian Daniel Headdrick proposed that quinine was at the core of European 19th century imperialism. He pointed to the failed expeditions into the African interior in the early part of the century, and contrasts them with the successful ventures in the decades after Britain and the Netherlands established their own cinchona tree supplies in India and Java respectively. His thesis presupposed that quinine or its quina bark precursor were widely available and widely consumed by the agents of empire. Other historians have since contested this claim, primarily because Headdrick was inferring rather than providing concrete data on the distribution and use of the antimalarial treatments. He offers information about the number of convicts who chose service to the Royal African Corps as an alternative to prison, but not how many of them were issued a supply of quinine to survive the endeavor. For example, two-thirds of Europeans who landed on the Gold Coast in the years 1823-27 died there; in total, 77 percent of the white soldiers sent to West Africa died, and 21 percent were permanently disabled by disease or violence. And though European invaders were susceptible to dysentery, yellow fever, typhoid, and other illnesses, malaria was the “principal killer” of Europeans in Africa. The deadliest strain of Plasmodium, Plasmodium falciparum, is endemic in tropical sub-suharan Africa, and killed its victims far swifter than those strains common in the Mediterranean.
Averill: Doctors in the early 19th century still practiced bleeding and purging to combat fevers, both of which tended to weaken patients, aiding the anemia and organ failure of malaria. But many individuals used quinine, even though it wasn’t compatible with humoral theory, before germ theory took root. For example, army physicians Jean Andre Antonini and Francois Clement Maillot rebelled against accepted military medical practices to treat intermittent fevers with quinine. According to Headdrick (though he doesn’t offer a citation to support this claim,) by the mid-1840s, Europeans on the “Gold Coast regularly kept a jar of quinine pills at their bedside.” He also points to statistics collected by the Royal Navy’s Africa Squadron, which reportedly noted a mortality rate drop from 65 per 1000 in 1825-45 to 22 per 1000 in 1858-67, which Headdrick attributes to shifting medical knowledge and practice, and the “prophylactic use of quinine” in the British military.
Marissa: Matthew Crawford has shown how in-demand quina bark was right up through the turn of the 19th century. Supply could barely meet demand. For two centuries, the bark itself remained expensive in Europe, controlled as it was by those with access to South American markets and the Spanish Crown’s monopoly. It’s associations with Catholicism made it suspect among some Protestant communities, and it didn’t actually fit into the humoral theory of medicine, but it remained the main treatment for malaria in Europe for over 200 years. In 1820, Pierre Joseph Pelletier and Joseph Bienaim Caventou perfected the process for extracting quinine, the natural alkaline that occurs in quina bark, in France. They quickly established a factory in Paris for the extraction of quinine, an activity that is often mentioned as the beginning of the modern pharmaceutical industry.
Averill: Even with the process for extraction perfected, the Dutch, British, and French all still needed to get a supply of bark, which meant they had to pay the market price. While they could still buy from the Andean countries – as previously noted, quina bark was still a major export – the Dutch and British preferred to control their own supplies to ensure they got the best price for the goods. By 1857, the British government in India was paying over 7000 a year on quinine, an untenable expenditure.
Marissa: To achieve a consistent and inexpensive supply, the Dutch, French, and British had two choices: produce a scalable synthetic, or plant their own supply. Scientists in all the major European empires were encouraged to seek out a synthetic formula. In 1850 the French Society of Pharmacy made a call to the chemists: “We make a call … offering the amount of 4000 francs to the … discoverer of the way to prepare synthetic quinine”. Participants were notified of the January 1, 1851 deadline and the requirement of submitting at least half a pound of the synthetic substance. Needless to say, nobody claimed the prize. A working synthetic would not be achieved until 1944.
Averill: So the only viable option in that intervening century was to establish supplies of the bark within the boundaries of respective empires. The Dutch and British both controlled territories that botanists believed would be favorable to the growth of the cinchona. In 1852, the Dutch government charged Justus Charles Hasskarl with collecting cinchona species samples for transplantation to Southeast Asia. British operatives like Richard Spruce, Robert Cross, and Clemens Markham similarly slipped into South America in the search for plants, seedlings, and seeds of cinchona.
Marissa: Like the Spanish conquistadors 300 years earlier, the British smugglers relied on indigenous knowledge to find and collect cinchona samples. Clements Markham, an English geographer and explorer, was working as an operative for the India Office in 1859. A colleague proposed that the India Office send someone to surreptitiously collect samples from Peru that the British might plant their own cinchona groves in India, which had regions that might be amenable to the growth of the finicky trees. Markham volunteered, and made his way to Peru, reportedly as a geographer come to map the land. He was on the expedition for nearly two years, and wrote up his adventures as soon as he returned for publication. Though he repeated the story of the Countess of Chinchona as the champion of the bark’s arrival in Europe, he did acknowledge his own reliance on indigneous guides, saying:
“I owe much to the intelligent assistance of our guide Martinez, who, to great experience in woodcraft, added a lynx’s eye for a Calisaya-plant; and it required no little quickness and penetration[Pg 250] to distinguish these treasures, amidst the close entanglement of the undergrowth, in the dense forests. Martinez spoke Spanish very imperfectly, and, without a knowledge of Quichua, I should have found much difficulty in conversing with him; but he had a most complete and thorough knowledge of all forest-lore, and was acquainted with the native name of almost every plant, and with the uses to which they were or might be applied.”
Averill: When Markham arrived in Lima with his team, which included botanist Richard Spruce and Kew gardener Robert Cross, they encountered a country on the brink of war. Peruvian authorities were heavily invested in protecting their cinchona, which was a major export for the country, and in addition to patrolling their borders to defend against Bolivian attacks, they had armed and dangerous soldiers available to defend the cinchona groves. Of course Markham’s own account he does not suggest that there might be some illegality in his maneuvering through Peruvian land to collect specimens without explicit permission from the Peruvian government. Despite the dangers, Markham collected seeds and seedlings from all the varieties of cinchona save one, and dispatched them to the West Indies and India for attempted cultivation, and all within just a few months. Cross and Spruce collected 100,000 cinchona succirubra seeds, and 637 young plants. 463 seedlings successfully reached India. Their efforts to find samples and then transplant them mostly failed, but the British had some success in Ceylon and India. Within 20 years of the Markham expedition, the Indian groves produced nearly 5,000 tons of bark.
Averill: According to Kal Rustiala, “By the 1840s British citizens and soldiers in India were using 700 tons of cinchona bark annually for their protective doses of quinine.” Quinine powder was bitter and slightly lemony, generally mixed with water, or compacted into pills to swallow whole. British operatives and soldiers in India took to mixing their quinine with sugar and soda water, the first homebrew “tonic” water. According to the Erasmus Bond tonic company, “in 1858 a man called Erasmus Bond patented an “improved aerated tonic liquid”. He was the very first to combine the quinine with a whole range of other flavouring agents. Tonic was born.” Quinine was repackaged as tonic water across the British empire by the 1860s, with companies like Schweppes jumping into the market in the 1880s. Agents of the British Empire from Nigeria to India mixed it with a splash of gin to further mask the bitter quinine. And so was the national British cocktail born – a defense against malarial fever consumed in vast boozy quantities for over a century. Winston Churchill is alleged to have said that, “The gin and tonic has saved more Englishmen’s lives, and minds, than all the doctors in the Empire.”
Marissa: Though the British had enough success to establish a ruling colonial elite of white Brits, Scotsmen, Irish, and Welsh in India, it would ultimately be the Dutch who dominated the quinine market from the late 19th century until the invention of the synthetic replacement in 1944. The Dutch had a great deal more success in Java, with seeds purchased from a British trader in Peru. At first, most cinchona operations were privately owned by Dutch farmers and businessmen. European quinine manufacturers relied heavily on the Dutch suppliers, but worked together to drive the price of the bark down even as they increased the price of the quinine alkaline. By the 1890s, the Dutch government stepped in. In 1893, the Java bark farmers asked the Dutch government to intervene in the artificially low bark prices. At the same time, the Dutch Minister of Colonies, W.K. baron van Dedem asked the quinine traders and manufacturers to explain the low price for bark. While he was dissatisfied with their justification, the Dutch maintained a commitment to liberal market policies, and refused to intervene directly. Fortunately for the Dutch planters, though, the Dutch government helped keep them afloat while the global market prices drove other planters out of business. And then the Dutch built their own quinine manufacturing plants, the first outside of Europe or South America. By the end of the 19th century, the Dutch became the world’s largest supplier of both cinchona bark and quinine.
Averill: Dutch success proved particularly important to the original European sufferers of malaria: the Italians! For much of the global life of quinine, the Italians had no central government or system to address the widespread issue of malaria, which really plagued the southern Italians the most. The city of Rome and Roman Compagna were, for centuries, heavily afflicted by a seasonal manifestation of the parasite. It was so ubiquitous in Rome that malarial fever was also known as the “Roman fever.” Every summer the wealthy fled the city for cooler climes. The poor suffered greatly. Well before Italian unification and any thought of a centralized response to malaria, Rome was the malaria capital of the 17th century European world.
Marissa: In the 1860s, Italy unified. With central government came all the challenges of administering a country with different regional problems. Malaria proved a testing ground of sorts for the Italian government. According to Frank Snowden, “The full extent of the prevalence of malaria first captured national attention in the decade following 1878.” The very first prime minister of united Italy died of malaria in 1861, just after unification was completed. But knowledge of malaria was still sparse. The parasite that causes malaria wasn’t discovered until 1880, when French physician Alphonse Laveran discovered it in a patient’s blood. Malaria had plagued the Italian peninsula (and especially its poor and rural folk) for centuries, but the 1870s–after unification–was the first time any centralized body attempted to assess the damage it caused.
Averill: Italy’s attempt to build a national railroad was (sorry) railroaded by malaria. In 1878, 1,455 of the 2,200 railroad workers in Sicily required medical attention for malaria. Government inquiries between 1860-80 revealed that Italian farming was far behind American and Russian competitors, that the Italian countryside was “squalor,” that the Italian peasantry was more sickly than any other European population, and all because of malaria. According to Snowden, “In 1887 the Italian state launched a second investigation by beginning to collect and publish health statistics. Declaring malaria a reportable disease, the Department of Health (Direzione Generale della Sanità) produced a statistical profile that illustrated the urgency of taking action.”
Marissa: The investigation found that, of Italy’s 8,362 townships (comuni), 3,075 were
malarial. The greatest challenge to dealing with malaria was that the zones most susceptible were its most fertile zones–and the fertility was facilitated by the conditions that encouraged malarial transmission. One proposed solution, when the miasma theory still dominated, was to implement widespread drainage. That required massive infrastructural investment, however, and threatened the fertility of Italy’s largely grain-producing agricultural model. Members of the “antimalarial crusade” that coalesced around the issue tried to implement screen-use across the country, but because one or two mosquitoes always got in despite screens, and the screens made them feel like they were in cages, the rural population ripped out the screens, using them as sieves for tomato sauce. Treatment, according to Italian experts, was a more effective approach. So starting in 1904, the Italian government started purchasing quinine wholesale.
Averill: According to Snowden, “As early in the campaign as 1906, the provincial officer of health reported that the city had organized a service of prophylaxis and care that was ‘‘above all praise,’’ distributing quinine preventively to 9,415 healthy peasants and treating 2,474 fever patients.” Education too became essential to the antimalairal campaign – as with any public health crisis – and the government integrated antimalarial measures into the peasant school curriculum. While their parents and grandparents resisted the prophylactic measures like screens and mosquito nets, the education efforts were more effective with raising a new generation of rural folk who understood the disease, its origins, and how to avoid it or treat it.
Marissa: Early 20th century efforts made great strides toward addressing Italy’s malaria problem. Government-provided quinine and treatment stations were essential to that effort, as would be education. Still, Southern Italians emigrated by the thousands for less malarial climes, heading to North and South America. And in 1914, World War I broke out, and much of the Italian government’s antimalarial efforts were disrupted, but not derailed. The antimalarial campaign had major long-term implications for Italian life and politics. Its reliance on women as teachers, mothers, and health care providers empowered a generation of Italian feminism; its requirement of a centralized government providing free health care to its citizens shaped the rise of Italian socialism. Antimalarial campaigners had to advocate for workers rights – ensuring that laborers had access to enclosed accommodations, for example, and other prophylactic measures to ensure both their ability to continue working and to preserve their individual health.
Averill: Quina bark and quinine were essential to all of that work, and helped to reshape early 20th century Italy in ways that would have permanent effects, just as it facilitated the spread of British, Dutch, and French imperialism, propped up early 19th century Andean economies and wars of independence, and created entirely new industries – from the manufacturing of quinine itself on three continents, to the invention of the fizzy tonic water that saved as many Brits as it intoxicated. It’s even the root of homeopathy, the medical theory that “like cures like.” (German physician named Samuel Hahnemann, fever, etc.) I think it’s interesting the ways that the knowledge and commodities that Europeans appropriated and stole in the so-called “Age of Exploration” would go on to reshape the world, and the ripple effect of a single pebble dropped in the pond. Quina bark is definitely one of those pebbles. It protected indigenous Andeans from being ravaged by yet another European disease, but also allowed the British to better control India and the Belgians to dominate the Congo, and also completely changed the lives of rural Italians for the better. Talk about a globalization story. The end.
To be honest, I picked this topic because I read Natasha Pulley’s Bedlam Stacks years ago, and because of that book, which buries quina bark in a world of magical stone guardians and same-sex love, I’ve since been thinking about quinine more than I think about most herbal remedies.
Jane Achan, Ambrose O Talisuna, Annette Erhart, Adoke Yeka, James K Tibenderana, Frederick N Baliraine, Philip J Rosenthal, and Umberto D’Alessandro, “Quinine, an old anti-malarial drug in a modern world: role in the treatment of malaria,” Malaria Journal 2011; 10: 144.
Lucile H. Brockway, Science and Colonial Expansion: The Role of the British Royal Botanic Gardens (Yale University Press, 2002)
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 Teodoro S. Kaufman and Edmundo A. Rfflveda, “The Quest for Quinine: Those Who Won the Battles and Those Who Won the War,” Angew. Chem. Int. Ed. 2005, 44, 854-885; 855.
 Toshiyuki Hayakawa, Richard Culleton, Hiroto Otani, Toshihiro Horii, Kazuyuki Tanabe, “Big Bang in the Evolution of Extant Malaria Parasites,” Molecular Biology and Evolution, Volume 25, Issue 10, October 2008, Pages 2233–2239.
 Kaufman and Rfflveda, “The Quest for Quinine,” 855.
 Matthew Crawford, The Andean Wonder Drug: Cinchona Bark and Imperial Science in the Spanish Atlantic, 1630-1800, (University of Pittsburgh Press, 2016) 34.
 Jeffrey Klaiber, “The Jesuits in Latin America: Legacy and Current Emphases,” International Bulletin of Mission Research (April 2004).
 Kaufman and Rfflveda, “The Quest for Quinine,” 856.
 See for example Jane Achan, Ambrose O Talisuna, Annette Erhart, Adoke Yeka, James K Tibenderana, Frederick N Baliraine, Philip J Rosenthal, and Umberto D’Alessandro, “Quinine, an old anti-malarial drug in a modern world: role in the treatment of malaria,” Malaria Journal 2011; 10: 144; and G. Dennis Shanks, “Historical Review: Problematic Malaria Prophylaxis with Quinine,” Am J Trop Med Hyg. 2016 Aug 3; 95(2): 269–272.
 Clements Markham, Travels in Peru and India, (London: John Murray, 1862). Digitized by Project Gutenberg: http://www.gutenberg.org/files/55593/55593-h/55593-h.htm
 Matthew Crawford, The Andean Wonder Drug: Cinchona Bark and Imperial Science in the Spanish Atlantic, 1630-1800, (University of Pittsburgh Press, 2016) 30.
 Crawford, The Andean Wonder Drug, 34.
 Crawford, The Andean Wonder Drug, 4.
 Kaufman and Rfflveda, “The Quest for Quinine,” 856.
 Stefanie Gänger, A Singular Remedy: Cinchona Across the Atlantic World, 1751–1820 (Cambridge University Press, 2020) 5.
 Ganger, A Singular Remedy, 1-2.
 Crawford, The Andean Wonder Drug, 4.
 Crawford, The Andean Wonder Drug, 44.
 Crawford, The Andean Wonder Drug, 14-15.
 Crawford, The Andean Wonder Drug, 36-39.
 Kaufman and Rfflveda, “The Quest for Quinine,” 856.
 Crawford, The Andean Wonder Drug, 57.
 Crawford, The Andean Wonder Drug, 176.
 Crawford, The Andean Wonder Drug, 177.
 Daniel Headdrick, The Tools of Empire: Technology and European Imperialism in the Nineteenth Century (1981).
 Lauence Monnais, “‘Rails, Roads, and Mosquito Foes’: The State Quinine Service n French Indochina,” Imperial Contagions: Medicine, Hygiene, and Cultures of Planning in Asia (Hong Kong University Press, 2013) 195-278; 195.
 Headdrick, The Tools of Empire, 63.
 Headdrick, The Tools of Empire, 64.
 Headdrick, The Tools of Empire, 66.
 Headdrick, The Tools of Empire, 67.
 Headdrick, The Tools of Empire, 69.
 Kaufman and Rfflveda, “The Quest for Quinine,” 857-8.
 Kaufman and Rfflveda, “The Quest for Quinine,” 858.
 Crawford, The Andean Wonder Drug, 177.
 Kaufman and Rfflveda, “The Quest for Quinine,” 858.
 Clements Markham, Travels in Peru and India, (London: John Murray, 1862) 250.
 Headdrick, The Tools of Empire, 71.
 Andrew Goss, “Building the world’s supply of quinine: Dutch colonialism and the origins of a global pharmaceutical industry,” Endeavour Vol. 38 No. 1 (November 2013) 1; and Crawford, The Andean Wonder Drug, 12.
 Goss, “Building the world’s supply of quinine.”
 Frank M. Snowden, The Conquest of Malaria: Italy, 1900-1962, (Yale University Press, 2006) 7.
 Kaufman and Rfflveda, “The Quest for Quinine,” 856.
 Snowden, The Conquest of Malaria, 9.
 Snowden, The Conquest of Malaria, 10-11.
 Snowden, The Conquest of Malaria, 15.
 Snowden, The Conquest of Malaria, 75.
 Snowden, The Conquest of Malaria, 53.
 Snowden, The Conquest of Malaria, 55.
 Snowden, The Conquest of Malaria, 77.