As Dr. George Giglioli and Gina Perrett, his bride of 10 days, boarded the good ship Crjinsen of the Royal Dutch Mail in 1922, final destination: British Guiana, the mild-mannered Anglo-Italian physician did not know that the trip was the first leg of a 50-year journey that would eventually unlock the dark secret of malaria transmission in that faraway colonial dependency.

". . . Why did such a man, born of distinguished scientific and intellectual parentage in a Europe at the height of its power choose a career in the jungles of a country nobody at the time knew anything about?" muses Guyanese intellectual Denis Williams in his 1972 biography Giglioli in Guyana.

Until then, Giglioli's life had consisted of a series of seemingly small, random events that had unwittingly opened doors of opportunity; a thread that would weave itself throughout his life. Guyana was but one more of these chance occurrences. Yet it marked a turning point in the young doctor's life.

His original desire had been to study natural history. However, in 1915, during his last year of high school in his hometown of Pisa, Italy, he happened to meet Professor Ficalbi, a colleague of his father's at the University of Pisa and a mosquito expert. On hearing of young Giglioli's interests, Ficalbi advised him to study medicine if he wanted to travel overseas; by so doing, he would also be getting a solid background in the natural sciences that could be put to use in research. As Giglioli recalled in his unpublished memoirs penned six years before his death in 1975: "Few or any moments of my life have been as important for my career as that chance meeting and those few words of advice, casually spoken; they suddenly brought to light and polarised . . . plans and ambitions which had so far been latent."

The memoirs, entitled "Demerara Doctor: Confessions and Reminiscences of a Self-Taught Physician," bring to life a man of intelligence, wit, and compassion whose fight against tropical diseases--most importantly malaria--should be remembered not only for its historical importance but also for the lessons it can teach in the continuing struggle against these ills.

DDT and rapid air transportation revolutionized malaria control efforts, even in Guyana's previously inaccessible hinterlands. In 1947, Dr. Giglioli, far left in photo, was flown to a remote mountaintop to investigate an epidemic among the Patamona Indians. Nine days later, settlements over 270 square miles of rugged terrain had been sprayed and villagers treated. Photo: British Guyana Mosquito Control Service courtesy Dr. Harry Drayton

Born in 1897 to an Italian professor father and an English writer mother, Giglioli grew up speaking both parents' languages, plus French, fluently. During his first year of medical training at the University of Pisa, he was called up for military duty in World War I. Two months after entering combat, his platoon was captured and he spent the remaining 18 months of the war in a Austrian prison camp. With typical determination, he parlayed the nightmarish experience into what he called "the second phase of my medical studies," immersing himself in all the textbooks he could acquire and assisting in the treatment of fellow prisoners in the camp hospital.

When the war ended, Giglioli returned to Italy to resume his studies. Although he had missed two academic years, he caught up with his exams by the final year of the program and received his M.D., magna cum laude, on schedule in July 1921.

Giglioli knew exactly what he wanted to do next: continue his studies at the London School of Tropical Medicine, with an eye toward taking a job in one of the British colonies. Attending lectures, he came to appreciate "the biological complexity of tropical diseases, and the consequent necessity of a wide-angle naturalistic approach to most public health problems in hot climates." Much of the success of Giglioli's later work on malaria was grounded in this insight.

Soon after completing his London studies, he received word that a mining company in the interior of British Guiana was looking for a medical officer. He immediately signed on for a three-year tour of service, despite lingering doubts over the adequacy of his preparation for such an assignment.

Above: Night view of aluminum production at the Mackenzie mine. Photo: Robert Madden National Geographic Image Collection

Giglioli's new employer was Demerara Bauxite Company, Ltd., a subsidiary of the Aluminum Company of America (ALCOA). The mine was located near the settlement of Mackenzie, on the Demerara River 65 miles south of Georgetown. In 1923 the mine employed more than 1,000 workers, most of them working 10-hour days quarrying bauxite--the ore from which aluminum is extracted.

The company offered medical services to its employees and the surrounding population through a hospital in Mackenzie. When Giglioli arrived, he found that the hospital "was little more than a shack," had an untrained staff, and was seriously deficient in sterile procedures. Plans were approved for the construction of a new 60-bed hospital, which opened in May 1925. It featured X-ray and laboratory facilities, a sterile operating theater, and a trained staff that included professional nurses, and, later, a surgeon.

Mackenzie provided Giglioli with an all-too-vivid tableau of tropical disease problems to treat and study. Many patients were afflicted with multiple parasitic diseases, malaria and hookworm being the most common. The first public health problem he tackled was hookworm infection--which affected an estimated 80% of the population--by instituting a systematic mass treatment program. Even though he was a novice in the public health arena, Giglioli understood the importance of gaining public trust and cooperation in order to achieve good results. Hookworm was a good place to start, since people could understand the parasite ("worms") and know that the treatment had been effective. Aware that treatment alone was not enough and that reinfection must also be prevented, he spearheaded improvements in sewage disposal methods and provided the miners with adequate footwear (army surplus boots, purchased at cost). The prevalence of infection dropped to 6% and, much to the delight of management, worker productivity increased dramatically.

Malaria proved a much more intractable problem. Between 50% to 75% of all those who sought treatment at the hospital were suffering from malaria. The mosquitoes that carried the disease bred prolifically around Mackenzie following the May-July rainy season; there was no practical way to get rid of them or their breeding ponds. The only way to control the disease was through a prolonged course of the unpopular, bitter-tasting drug quinine.

In 1891 historian James Rodway wrote of Guyana's topography: ". . . every acre at present under cultivation has been the scene of a struggle with the sea in front and the flood behind." Over time, human engineering has turned tidal marshlands into a network of drainage canals and irrigation ditches suitable for sugarcane production. Photo courtesy Inter-American Development Bank

Circumstances at Mackenzie forced Giglioli to become a medical Jack of all trades, alternating as "the malariologist, the clinician, the pathologist, the bacteriologist, the medical officer of health and even the undertaker." But above all, he was, as Williams notes, the country's "first permanent medical research scientist," and his Demerara River studies provided the first pivotal observations on the relationship between the chemical properties of groundwater and the breeding habits of the malaria carrier (at that time still unidentified). His discovery that the mosquito could not breed successfully in acidic waters would lay the foundation for his later malaria work.

The Great Depression all but shut down the Mackenzie bauxite mine, and many staff--including Dr. Giglioli--were let go. Crestfallen at having to leave the land they had come to love, the family returned to Italy in 1932, where Giglioli hoped to find a university position. But Italy had changed: fascism was on the rise and employment chances were slim for anyone not a member of the Fascist Party, which Giglioli had no intention of joining. He writes: "After ten years in the bush, where with a gun and some fish hooks, no one need starve, the cities of Europe struck me as far more fearsome and inhospitable jungles than the forest I had left."

He was saved from those jungles by a business decision made half a world away. A deep recession in the sugar market was bringing foreclosure to one plantation after another. Davson & Co., which operated three sugar estates on the Berbice estuary in coastal Guyana, was the country's lone surviving family-owned company, and found itself battling for its existence alongside three larger companies which together accounted for 90% of Guyana's total sugar output. Always enterprising during its 100-plus years in British Guiana, Davson decided then and there to modernize and improve public health conditions in order to keep its workers from defecting to other estates and sought out Dr. Giglioli to become its medical officer.

Giglioli's first challenge was to rebuild the dilapidated estate hospitals and reorganize procedures--tasks for which his Mackenzie experiences had primed him. Infinitely harder was ameliorating his patients' malaria, anemia, and malnutrition. This called for long-term efforts to improve not just diet, but general living standards--housing, water supply, and sewage disposal--"so as to . . . cure and not to patch."

George Giglioli (back row at far right) and his World War I Italian military platoon. From Giglioli in Guyana 1922-1972. Georgetown: National History and Arts Council

In addition to his clinical duties, Giglioli continued his mosquito studies. It was during this period that Giglioli was able to pinpoint Anopheles darlingi as the main malaria carrier in Guyana.This discovery, along with the mosquito's known predilection for breeding in rainwater collections, irrigation canals, trenches, and rice and sugarcane fields in flood fallow, enabled him to predict how prevalent malaria would be in a given area. With the results of his Berbice estates surveys, Giglioli now began to fill in the epidemiologic picture of malaria on the Guyana coast.

In 1936, he was asked by Booker's, the country's largest sugar producer, to head a laboratory in Georgetown the company was setting up to conduct systematic medical surveys and improve health conditions on all the sugar estates in the country. "This was exactly the kind of development I had hoped for when I accepted the job with Davsons," wrote Giglioli. In 1939, another malaria milestone was achieved: a Malaria Research Unit was established with funds from the Colonial Government, the Rockefeller Foundation, and the British Guiana Sugar Producers' Association, and Dr. Giglioli was selected to head it.

Unfortunately, world politics intervened to interrupt the new Unit's work. On 10 June 1940, the day Italy entered World War II on the side of Germany, Dr. Giglioli was placed under house arrest as an "enemy alien." Along with other Italian and German residents of British Guiana, he was sent to the Mazaruni Penal Settlement--a prisoner of war for the second time in his life.

Eventually, the Colonial Government realized Giglioli was too valuable a resource to be locked up. In August 1942 he was released and obliged to accept the low-paying appointment of Government Malariologist.

The following year, three distinguished British scientists made an unscheduled visit to Guyana when their flight from Trinidad to Washington, D.C., was delayed for several days. They were interested in the country's malaria situation, and a meeting with Giglioli was hastily arranged. One of the scientists, Dr. Alexander King, talked about the new insecticide DDT, which the Allies were using as a "secret weapon" to protect their troops from malaria. Unlike other insecticides, it was applied to the surfaces where adult mosquitoes rested and a single application remained lethal for months. Giglioli immediately recognized the potential this technique offered. His own research had proved that A. darlingi sought shelter inside people's houses. Instead of trying to eliminate mosquito larvae--an impossible task given Guyana's hydrological patterns--it would be possible to target the adults. "A. darlingi," he told his British colleagues, "appears to be made to order for extermination by D.D.T.," and he asked for access to the insecticide to carry out a field experiment in malaria eradication, the first in the Western Hemisphere.

This Guyanese cane worker, as those in preceding generations, faces the high probability of eventually contracting malaria due to his close contact with irrigated fields where mosquitos carrying the disease breed. Photo: Robert W, Madden National Geographic Image Collection

A month later, the first 500-pound consignment was on its way to Guyana. The preliminary work needed for the field experiment--Giglioli's detailed mosquito and malaria surveys--had already been done. The trials expanded into a large-scale control program in 1946, and into a countrywide campaign in 1947.

By 1951, malaria and its principal carrier had been completely eliminated from the coastal areas, including Georgetown, by means of a highly focused house spraying campaign. In the interior, where settlements were widely scattered and difficult to get to, it was impossible to completely eliminate the disease. The mosquito lived in the forest there, not in houses.

Concerned about the sporadic outbreaks that continued to occur in the North-West District and the vast Rupununi savannahs, Giglioli decided to try a different technique. In 1961, with financial and technical assistance from the Pan American Health Organization (PAHO) and UNICEF, he launched a campaign to distribute salt treated with the antimalaria drug chloroquine to the populations of those remote areas. Although logistical problems limited its effectiveness in the Rupununi, the program quickly eliminated falciparum malaria (the most dangerous type) in the North-West. Throughout the 1960s, continued malaria surveillance revealed few cases in the entire country (as few as 22 in 1965), and most of those were introduced in areas near the country's borders. Malaria's grip had been broken.

George Giglioli's association with PAHO/WHO spanned several decades. In 1968, WHO World Health Assembly Chairman Dr. E. Aujaleu presented Giglioli with the Darling Foundation Medal and Prize. The award was named after U.S. malariolist Samuel Taylor Darling, whose name christened the Anopheline mosquito species which Giglioli pinpointed in the 1930s as Guyana's principal carrier of malaria. WHO Photo by T. Farkas

Guyana saw its overall health improve dramatically in the 1950s and 1960s. The sugar estates hospitals, previously overcrowded, became empty. Perhaps the most dramatic change was the reduction in deaths of women of child-bearing age and the increased survival of their offspring after malaria-induced anemia was no longer a threat.

Unfortunately, the story of malaria in Guyana does not end with the successes of 30 years ago. Since 1986 falciparum malaria has reappeared with a vengeance in the North-West District, reintroduced there by miners traveling from the Rupununi. In 1994, 39,566 malaria cases were reported in the country, and the index of parasites per 1,000 population in malarious areas was among the highest in the Americas.

The current situation would have saddened, but not surprised, Dr. Giglioli. At the end of his memoirs, he warned that early detection and laboratory services must be maintained at all costs; a few months of neglect, he wrote, could set the program back by years. But economic constraints in Guyana during the last decade caused antimalarial activities to be greatly reduced. That, compounded by a sudden influx of itinerant gold miners infected with the falciparum parasite, doomed hopes of maintaining a malaria-free situation. As Giglioli wrote, "of the three biological factors involved in malaria epidemiology--Plasmodium [a parasite], Anopheles, man--the latter is the least predictable and often the most difficult to deal with."

The coming of DDT to Guyana at a time when it was unavailable elsewhere was, in Giglioli's words, a truly remarkable chain of events "which gave Guyana, its Mosquito Control Service, and its Sugar Industry the opportunity to write so memorable a page in the history of man's long fight against malaria." Other circumstances have caused a reversal of some of the progress that the Demerara doctor's many years of dedication and hard work made possible. Yet his legacy lives on in the results he achieved and the example he set--with insatiable curiosity, courage in adversity, and a deep commitment to improving the health of his fellow human beings.

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Donna J. Reynolds is an editor in PAHO's Office of Publications and Editorial Services.