Could there be any greater tale about the history of malaria treatment than one involving the creation of gin and tonics? Winston Churchill himself said, “The gin and tonic has saved more Englishmen's lives, and minds, than all the doctors in the Empire.” Cinchona, otherwise known as Jesuit's bark, with its active ingredient quinine, was the savior of the British Raj, keeping troops in the low-lying wetlands of India alive and relatively malaria-free.
Quinine is bitterly unpalatable on its own, thus its marvellous marriage to sugar and soda and to the empress of liquors, gin. Surely there's no grander antidote and no better anecdote.
Well, hold on to your race-day fascinators.
First, as this is a sensible emergency medicine column, let us refresh our knowledge about the emergency management of malaria. We mostly concern ourselves with Plasmodium falciparum, the grievously serious parasite of the four species. The key is early suspicion, rapid diagnosis (the classic thick and thin films, plus a serum antigen test), and following your local infectious disease department's advice regarding resistance and sensitivity profiles. Today the first-line treatment is almost always a combination medication that includes a form of artemisinin.
The combination issue is paramount because the Plasmodium species has an unparalleled ability to become resistant to antimicrobials, a result of their huge genetic diversity and a genome that is constantly and rapidly mutating. We need to stringently avoid monotherapy and make the correct first-line choice. Our tonic-based quinine has had its day, now relegated to club drinks and the occasional intravenous rescue, and we need to graduate to newer agents. This is where the discovery of artemisinin comes in and where our story gets very, very interesting.
A Cure for Malaria
We need to jump sideways and a little backward once more to the Cultural Revolution in China. Euphemistically termed, this period was unfathomable in its cruelty, and was essentially Mao Zedong's brutal way of purging the Democratic Party and controlling the masses. It was unprecedented in its evil, bloodshed, and terror, targeting those with education and anyone with the slightest bit of status.
Mao's sights of control were set far afield, and he responded to a request from North Vietnam to help find a cure for chloroquine-resistant malaria, which was decimating the troops needed to fight the common enemy, America.
From this, Project 523 was born, a highly secretive search for new cures. Into this story now steps a remarkable woman. Tu Youyou, unenviably tasked by Mao himself, was set to work in the field and in books. Among the pages of an ancient Chinese text, she found her answer, using her training in pharmacognosy, in sweet wormwood, or qinhao, otherwise known as artemesia.
For a moment, however, let us leap not so much sideways but parenthetically. It's worth wondering why you haven't heard of this woman before (don't pretend you have; I hadn't). Or, in fact, now that you think about it, many women who made life-altering discoveries. Women in science are a historical rarity. The pages we read are predominantly seasoned with the exploits of men. The history of the world is the history of men. We have to ask ourselves why. Were women not as smart back then? Or is there another reason?
Let us leave this sticky question for a future column. It suffices to say that women were not commonly credited or did not feel comfortable taking credit for their achievements. Even this story ends with Tu apologizing for being, requesting that she is not recognized above her team.
Hero of Medicine
But let us step back out of our metaphorical brackets to her story. Tu sacrificed her role as a mother, giving up child and husband to do justice to this request. She reviewed thousands of Chinese traditional remedies, testing them in mice. Wormwood worked, but it could not survive the extraction processes.
So Tu scoured ancient Chinese texts, including one from 1500 years ago fabulously titled, “Emergency Prescriptions Kept Up One's Sleeves,” and realized it was the heat that was destroying the substance's therapeutic properties.
She went on to extract the artemisinin with ether, testing it on herself, and then, quite literally, saving the world. Tu's role was kept secret for 40 years. There was one textbook that talked of her achievements, but 97 percent of it was about the awesomeness of Chinese bureaucracy (written by the Chinese). She won a Nobel Prize in 2015, one of only 51 women to have ever done so, compared with 853 men.
Of course, the future of malaria treatment is not treatment at all. It's prevention of the disease in the first place. The headwinds hampering the efforts to achieve this remain strong but not impossible to overcome. In the meantime, it is wonderful to be able to pay homage to a hero of medicine.
Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, http://michellejohnston.com.au/. She also contributes regularly to the blog, Life in the Fast Lane, https://lifeinthefastlane.com. Follow her on Twitter @Eleytherius, and read her past columns at http://bit.ly/EMN-WhatLiesBeneath.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.