On the Track of a Shifty Bug

It starts with a high fever and a severe headache, accompanied by swollen glands, vomiting and general pain. Left untreated, the malady gradually worsens. After several months, victims become irritable, then lethargic and sleepy. When they try to walk, they are likely to stumble about with a peculiar shuffling gait. Soon they can no longer stand, sit erect or even eat; often they fall into a coma and die. Their illness is African sleeping sickness, or trypanosomiasis --an ancient scourge that afflicts at least 10,000 people a year.

For decades doctors have been battling the parasitic disease with the few available drugs, usually arsenic compounds. At the same time, local and international agencies have waged campaigns to eradicate tsetse flies, the bloodsucking insects that transmit the ailment to domestic cattle and man. Neither approach has been particularly successful. Trypanosomiasis still casts its shadow over 35 million people who live in the heart of tropical Africa, the tsetse fly's breeding ground, making huge areas all but uninhabitable.

Now a small but significant first step may have been taken in the conquest of a disease so frightening that it is enshrined in the old Lingala curse "Owa na ntolo " (May you die of sleeping sickness). At Nairobi's International Laboratory for Research on Animal Diseases (ILRAD), a team of scientists has managed to grow in the test tube the long, slender, infective form of the single-celled parasite Trypanosoma brucei. That feat--accomplished by Hiroyuki Hirumi, a Japanese-born American scientist, and John Doyle, a Scottish colleague--has been the aim of medical scientists for years. In the past, whenever researchers tried to culture the bug, it invariably reverted to a harmless form. Thus they were unable to learn much about the deadly parasite--to say nothing of devising weapons against it.

Hirumi concocted a novel brew that contained cells from the lung fluid of cows and serum from fetal calves. In effect, the formula fooled the parasite into acting as if it were in a natural host. Yet trypanosomes are exasperatingly fickle creatures. After they invade humans or cattle, they show a chameleon-like ability to change their protein coatings, whose molecular structure serves as a precise signal to the host's immune system for the production of specific antibodies against the invaders. As the immune system begins mustering appropriately shaped antibodies against the trypanosomes, the parasites change their coats and force the immune system to mount a new counterattack. This game of immunological hide-and-seek recurs throughout the course of the disease. The parasites become more and more deeply entrenched in the victim's brain and nervous system, and the patient progressively weakens.

The ILRAD team's next objective is to understand the mechanism that orders these changes in the parasite's coating. That knowledge could perhaps be used to fashion an effective vaccine or more potent drugs against sleeping sickness. If Hirumi or any other scientist were to realize that long-sought goal, it could open up millions of acres of fertile, yet largely idle land in Central Africa to people and their livestock.

Hospital Without Walls

For the past 18 months, Susan Foss has been paralyzed from the neck down with a spinal tumor. Anywhere else in the world, the pretty, 20-year-old Auckland, New Zealand, housewife would probably be confined to a hospital for the rest of her life. Yet, except for a few hours each day when she undergoes physical and occupational therapy at a nearby hospital, Susan spends all her time at home. Her routine needs are met either by her husband Chris or by a nurse and a home aide who regularly visit the Foss household.

Susan Foss is only one of thousands of seriously ill people who are participating in an extraordinary program of outpatient hospital care. Begun in 1960 to cut rising costs of New Zealand's largely free, womb-to-tomb national health system, the scheme has kept expenses at about 500 a day for each extramural patient in the greater Auckland area (pop. 800,000), compared with the average $41 daily price tag for in-patient care. It has also saved at least 3,000 additional hospital beds, while at the same time making life more bearable for tens of thousands of patients.

Auckland's "hospital without walls" is aimed not so much at eliminating hospitalization as at shortening it. Barring unforeseen complications, patients who have undergone gall-bladder operations, for example, are sent home only five days after surgery--compared with a typical ten-day hospital stay in the U.S. For these Auckland patients, however, hospital care continues at home. Nurses pay them regular visits. Family members are trained to meet their special needs. Patients may even borrow hospital equipment. It may be an everyday item like a bedpan or cane--or more complicated gear: a respirator, wheelchair or even an electrical hoist like the one that helps Susan Foss out of bed.

Beyond these services, the extramural-hospital system offers the stay-at-homes trained therapists and household help. Such aid is particularly important for elderly couples if, say, one partner has had a stroke and the other can no longer cope with the chores. A "meals-on-wheels" service, manned by volunteers--mainly from the Red Cross--delivers some 1,000 hot trays a day. If the patient needs help, the volunteer can quickly summon a nurse, social worker or the patient's family physician, who retains overall charge of the case. Says Susan Foss: "Five days a week I await the footsteps of the people from Extramural and their bright faces."

Just as important, the hospital without walls gives long-term patients the comfort and reassurance of familiar surroundings. Neil Ballantyne, 74, a retired accountant, has been bedridden with emphysema and a fractured spine for more than two years. Although he sometimes needs a respirator or other special equipment, he has not been hospitalized since 1973. Says he: "This service is marvelous because it enables me to be at home, where I want to be, instead of in the hospital forever."

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