No Cure for Malaria

The conservative New England Journal of Medicine recently jumped on "the erroneous conception that malaria can be eradicated by means of a five-day treatment with the synthetic drug, atabrine." Attacking an article ("Enter Atabrine--Exit Malaria") written by Paul de Kruif in the Reader's Digest, the Journal pointed out that there is as yet no sure cure for malaria, that the disease and its problems are anything but simple.

The protozoa which cause the disease are carried by about 60 kinds of mosquitoes and are of four main varieties, each producing its own form of malaria: 1) Plasmodium vivax produces the mildest disease, benign tertian malaria; 2) P. malariae bring on quartan malaria, the most difficult to eradicate; 3) P. falciparum produces dangerous malignant tertian malaria; 4) P. ovale produces symptoms similar to those of benign tertian malaria.

Mosquitoes carry the protozoa on their stomach linings and in their salivary glands. While in the mosquito the protozoa are in the sexual phase of their cycle; man's blood stream is the home of the asexual phases. In an active case of malaria a patient's blood teems with asexual forms which multiply in the red blood cells, burst out bringing poisons with them. A few sexual forms of protozoa are produced in the human body, but they cannot multiply sexually unless a mosquito carries them off, thus completing the cycle.

Malaria is fought by fighting mosquitoes or by interrupting the plasmodia life-cycle at some point. Men use old-fashioned mosquito nets, oil on mosquito-breeding water, citronella to keep from getting the dangerous mosquito bites. In some parts of India the U.S. Army does not employ native labor lest the mosquitoes pick up plasmodia from their blood. Antimalarial chemicals can kill sexual forms of the protozoa in a patient's blood, prevent a mosquito from carrying his infection to others. No known chemical kills plasmodia in the form mosquitoes deliver to man. Chemicals can get them after they change their shapes and start dividing, prevent development of symptoms. If symptoms develop, chemicals can usually help a patient get well--at least from that attack--by killing them in the circulating blood. But a round of malaria, unlike whooping cough, does not prevent a patient from coming down with it again.

No one of the antimalarial chemicals in use does all the jobs a perfect antimalarial should do:

> Quinine, the old standby, is now available only from the not-very-large stocks which were in the U.S. when Japan invaded the East Indies. It acts by destroying the asexual forms of all kinds of plasmodia in the human blood stream--the forms which produce the shivering, sweating and fever. Quinine also destroys the sexual forms of all but P. falciparum, which means that even after he is "cured" by quinine a patient with malignant tertian malaria can give the protozoa to any suitable mosquito.

> Atabrine, a drug developed in Germany, does what quinine does and with smaller dosage. But its action is slower, it is a little more toxic and is excreted so slowly that doctors have to take care lest it accumulate in the body and do harm. Like quinine, it does not kill sexual forms of malignant tertian malaria. There is plenty of atabrine.

> Plasmochin, another synthetic, does not kill asexual forms of the protozoa unless given in toxic doses, is therefore not used for eradicating symptoms. But in very small amounts it kills all sexual forms, is therefore used to supplement quinine or atabrine to prevent convalescents from passing protozoa on to mosquitoes. Plasmochin is safe to give simultaneously with quinine, but some doctors believe it produces toxic effects if given along with atabrine, advise waiting a few days after atabrine before giving it.

> Totaquine, like quinine, is made from cinchona bark, but fewer bark components are discarded. What little comes from South American cinchona trees serves as a wartime substitute for quinine.

The National Research Council's advice on how these antimalarials should be used, especially among fighting men, until the Dutch quinine groves are recaptured from the Japs:

> Use atabrine instead of quinine as a "suppressive."

> If symptoms develop, start with quinine or totaquine, if possible, until fever goes down (about two or three days), follow with atabrine (about five days). After a two-day respite, give plasmochin.

> If no totaquine or quinine is available, or if a patient has benign tertian malaria, treatment can begin with atabrine.

But after any treatment is taken, protozoa may hide out in tissues like the liver or spleen, pop up to plague a "cured" man months or years afterwards; and a patient who succeeds in becoming completely free of the parasites has no true immunity, is liable to reinfection if an infected mosquito bites him. And there are always some mosquitoes with malarial stomach ulcers threatening the human race in the tropics.

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