One Remarkable Woman

Could there be any greater tale concerning the history of malaria treatment than that 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 saviour of the British Raj, keeping troops in the low-lying wet of India alive and relatively malaria free. The quinine was bitterly unpalatable on its own, thus its marvellous marriage to sugar and soda, and thence with the empress of liqueurs, gin. Surely there’s no grander antidote, and no better anecdote?

Well hold onto your race-day fascinators. There is.

Firstly, 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. The key is early suspicion, rapid diagnosis (both the classic thick and thin film, plus a serum antigen test), and following your local Infectious Disease department’s advice regarding resistance and sensitivity profiles. Today the first line is almost always a combination medication that includes a form of artemisinin. The combination issue is paramount – this is because the Plasmodium species have 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 must make the correct first line choice. Our tonic based quinine has had its day, relegated to club drinks and the occasional intravenous rescue. Hence the need to graduate to newer, novel agents. This is where the discovery of artemisinin comes in, and where our story gets very, very interesting.

We need to jump sideways and a little backwards 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 Party and controlling the masses. It was unprecedented in its evil, bloodshed and terror, particularly targeting those with education and anyone with the slightest 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 troops when they were 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 one remarkable woman. Tu Youyou, unenviably tasked by Mao himself, was set to work both in the field and in the 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 at all who have 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, suffice to say that women were not commonly credited, or did not feel comfortable taking credit, for their achievements. Even this story ends with Youyou apologising for being, in fact requesting that she is not, recognised above her team.

But let us step back out of our metaphorical brackets to the story of Youyou. She sacrificed her role of 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 standard extraction processes. So Youyou scoured ancient Chinese Texts, including one from 1500 years ago, fabulously titled: “Emergency Prescriptions Kept Up One’s Sleeves”, and realised 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. Youyou’s role was kept secret for forty years – there was one textbook written that talked of her achievements, but 97% of it was about the awesomeness of Chinese bureaucracy (written by the Chinese). In 2015, she won a Nobel Prize, one of only 51 women to have ever done so (compared to 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. Chin chin, and bottoms up, Tu Youyou.