The ‘Duke’ and the secondary stories behind this year’s Nobel Prize for Medicine

Duke Ellington was once asked what his favourite type of music was. “There are only two types of music”, he replied, “either good music and bad music”. And the same can surely be said of medicine.

 

The Nobel Award

 

This week an elderly and very modest Chinese researcher called Dr Tu Youyou has been belatedly co-awarded the Nobel Prize for Medicine for her meticulous research into the anti-malarial drug Artemisinin. This is a drug that has been subsequently hailed as the most important development in the treatment of malaria since quinine, so her story is surely one of good medicine – and so it’s been reported so in the media this week. In fact her own personal story is not just one of dedication, but also passion and bravery. There is also some very bad medicine that unravelled behind her discovery, however, and this hasn't been told this week, though it surely deserves telling just as much as her own one. It's a story of very bad medicine indeed and tells us a lot about the politics of global medicine today.

 

Artemisinin was first being identified outside China as a viable treatment for malaria back in 1979. But it was more than a decade earlier in 1967 that a group of Chinese researchers including Dr Tu Youyou had begun examining their culture’s traditional medical literature and realised that Qinghao, (Artemisia annua), or Sweet Wormwood had been being used in China as a tea to reduce malaria symptoms for sixteen hundred years right into the modern era. One of its chemical derivatives, Artemisinin, was then found by the same Chinese researchers to be even more powerful in its anti-malarial effects.


The ‘genocidal’ delays in the drug's roll-out


Their initial research coincided with America’s Vietnam War which provided reason enough, as far as Chinese politicians were concerned, to keep their researchers’ initial discoveries under wraps. Tu’s work wasn’t actually published until 1977 and, as was the custom in China at the time, the author of the study remained anonymous. It was a full six years after the end of the War, however, in 1979, when Dr Keith Arnold, a malaria researcher based in Hong Kong, first began hearing about the drug. He wangled his way into the PRC in the hope of finding out whether mefloquine, the drug which he had himself had helped develop with the U.S. Army (and which had been widely used in Vietnam), could outperform the artemisinin variants which he was hearing were still being developed within China. It turned out that all of his efforts on behalf of mefloquine failed - Artemisinin proving far more effective in every laboratory test. But the Chinese still stayed coy about their drug, leaving Arnold uncertain even as to what plant the drug had been derived from - ethically not good medicine at all. But then this type of bad medicine took a turn for the worse.


By 1982 Sweet Wormwood had been positively identified as the principal component for the drug’s synthesis and it had also been revealed to be an endemic plant in the U.S. (even growing on the banks of the Potomac in Washington DC). But, in spite of this, the desperately needed new drug for malaria ended up languishing on shelves because of conscious institutional neglect and inertia. The WHO actually failed to endorse the drug until as late as 2000, and even then it remained generally unavailable until 2006. So a full 26-year period went by between Arnold’s first encounter with it and its full availability – and 39 years had passed since this Nobel Prize winning research was first begun. If that’s not a story of very bad medicine indeed, it’s difficult to know what is.


The reasons for this delay may well have been complex, but they can’t possibly be excused given what was at stake. With nearly a million children a year at that time estimated to be dying from malaria in Africa, Arnold didn’t hold back on the matter, branding the delay “genocidal” (whether it was  caused by over-caution, negligent indecision or simple incompetence). Given that perhaps as many as 25 million children died in the hiatus period and the fact that the drug has since been hailed as the most important development in malaria since the introduction of quinine, his anger was surely understandable.


As far as we know, Dr Arnold never met Dr Tu, but they surely would have got on if they had. “It is scientists’ responsibility to continue fighting for the healthcare of all humans,” says Dr Tu, and Dr Arnold sang from the same hymn sheet. So good on Dr Arnold! – and congratulations to Dr Tu! – but shame upon shame on those politicians in the PRC, as well on those in Geneva who held up the roll-out of the drug for so long for whatever reasons.


Incidentally, it’s worth noting that the WHO was founded in 1948 with a global remit to tackle three specific diseases – venereal disease, malaria and TB. Their record on the latter two is still hardly yet worthy of any award and certainly doesn't make for atune the Duke might have tapped his feet to. In a couple of weeks the Organisation will be releasing this year’s Global Report on Tuberculosis and its possible contents fill us with trepidation because we already fear that it will contain evidence of similarly bad medicine. We will report on it as soon as we have full access to the Report and have been able to digest it.)