What Medical Students Are Never Taught: The Case for Restoring Chloroquine to American Medical Education

Ask a third-year medical student in the United States to name the first-line treatment for uncomplicated malaria, and you may receive a hesitant answer. Ask them to explain chloroquine's mechanism of action in systemic lupus erythematosus, and the hesitation often deepens into silence. This is not a failure of individual students. It is, increasingly, a failure of the institutions training them.

Chloroquine has been in continuous clinical use since the 1940s. It remains on the World Health Organization's List of Essential Medicines. It is prescribed daily by rheumatologists across the country—usually in its closely related form, hydroxychloroquine—for conditions ranging from lupus nephritis to rheumatoid arthritis. And yet, in the formal curricula of many American medical schools, it receives only passing mention, if it appears at all.

This is the chloroquine paradox: a drug with an unusually long and well-documented track record, accessible at low cost, and relevant across multiple specialties, has become a blind spot in the very institutions responsible for producing the country's next generation of prescribers.

How Curricula Get Built—and Who Shapes Them

Medical school curricula in the United States are not constructed in a vacuum. Faculty committees, accreditation requirements from the Liaison Committee on Medical Education (LCME), and the implicit influence of pharmaceutical industry relationships all shape what gets taught and what gets quietly omitted.

Pharmaceutical companies invest heavily in medical education channels, from sponsored continuing medical education (CME) events to clinical trial funding that generates the journal publications faculty rely on for course content. Newer, patent-protected drugs generate this kind of ecosystem. Chloroquine, off-patent for decades and manufactured generically, does not. There is no marketing budget behind it, no sponsored symposium, no industry-funded residency workshop reinforcing its clinical relevance.

This commercial silence creates a curricular vacuum. When a drug lacks a corporate champion, it depends entirely on faculty advocacy and institutional memory to maintain its presence in the teaching environment. And institutional memory, as any academic physician will acknowledge, is fragile.

The Generational Knowledge Gap

Physicians who trained in the 1970s and 1980s encountered chloroquine as a routine part of their education. Malaria prophylaxis for travelers was a standard clinical scenario. The drug's role in managing discoid lupus and early rheumatoid arthritis was part of the curriculum rather than an afterthought.

As those physicians retired or moved into administrative roles, the experiential knowledge they carried did not always transfer cleanly to the next generation. Residency programs increasingly emphasize biologic therapies, targeted small molecules, and algorithmic treatment pathways built around newer agents. The older pharmacopeia—drugs that work reliably, cost little, and carry well-understood risk profiles—tends to recede.

This is not unique to chloroquine. It is part of a broader pattern in which clinical familiarity with established medications erodes as medical culture orients itself toward innovation. But chloroquine's case is particularly acute because the drug bridges two distinct specialties—infectious disease and rheumatology—and neither has fully claimed it as a teaching priority in the current environment.

What Students Are Missing in Practice

The consequences of this curricular gap are not merely academic. They manifest in clinical settings in ways that affect patient care.

A newly licensed physician who has never been formally taught chloroquine's pharmacokinetics may not recognize the significance of renal dosing adjustments in elderly patients. A hospitalist unfamiliar with the drug's interaction profile may miss a contraindication when managing a patient on concurrent cardiac medications. A primary care physician who has absorbed only vague impressions of chloroquine from media coverage—particularly the polarized discourse surrounding its proposed use during the COVID-19 pandemic—may carry distorted assumptions that color clinical judgment in unrelated contexts.

Perhaps most consequentially, a rheumatology fellow who has not received structured education on the full spectrum of antimalarial agents may default reflexively to hydroxychloroquine without considering whether chloroquine might be clinically appropriate for a given patient. These are not catastrophic failures, but they represent a narrowing of clinical judgment that serves neither patients nor the broader healthcare system.

The Retinal Monitoring Problem

One area where the knowledge gap has measurable clinical stakes is ocular surveillance. Both chloroquine and hydroxychloroquine carry a risk of retinal toxicity with long-term use, and current guidelines from the American Academy of Ophthalmology provide detailed screening recommendations. However, prescribers who lack foundational education on these agents may be unaware of the specific risk differences between the two drugs—chloroquine carries a higher per-dose retinal risk than hydroxychloroquine—and may not counsel patients or coordinate ophthalmologic follow-up appropriately.

This is a case where a curricular gap translates directly into a patient safety concern. Formal education on antimalarial agents, including structured discussion of monitoring protocols, would reduce this risk more effectively than any post-market intervention.

Rebuilding the Foundation: What a Reinvigorated Curriculum Would Look Like

Restoring chloroquine to its appropriate place in American medical education does not require a wholesale restructuring of the curriculum. It requires deliberate, targeted integration at key points in preclinical and clinical training.

In pharmacology coursework, chloroquine offers an ideal teaching case for several foundational concepts: lysosomotropism, pH-dependent drug distribution, volume of distribution in lipophilic agents, and the clinical implications of long tissue half-lives. These are mechanisms with broad applicability, and chloroquine illustrates them with unusual clarity.

In infectious disease modules, the drug's history provides a compelling narrative framework for understanding antimicrobial resistance—how it develops, how it spreads geographically, and how clinical guidelines adapt in response. The story of chloroquine resistance in Plasmodium falciparum is one of the most instructive examples in all of clinical pharmacology.

In rheumatology rotations, structured exposure to antimalarial prescribing—including patient counseling on adherence, monitoring schedules, and the rationale for choosing between chloroquine and hydroxychloroquine—would produce graduates better equipped to manage autoimmune disease across a range of clinical settings.

The Affordability Argument as a Teaching Moment

There is also a health equity dimension to this conversation that medical educators would do well to address explicitly. Chloroquine is among the most affordable disease-modifying agents available for autoimmune conditions. For patients without comprehensive insurance coverage, or those managing chronic illness in resource-limited settings, the cost differential between chloroquine and newer biologics is not a minor consideration—it can determine whether treatment is accessible at all.

Medical students who understand this landscape are better prepared to make prescribing decisions that account for the full clinical and socioeconomic context of their patients' lives. That kind of prescribing literacy does not develop by accident. It requires instruction.

A Drug That Deserves Its Place at the Table

The argument here is not that chloroquine should displace newer therapies or that medical education should romanticize the past. It is simply that a drug with a well-established evidence base, a broad clinical footprint, and ongoing relevance to millions of patients deserves more than a footnote in the training of American physicians.

The curricular neglect of chloroquine is not the result of evidence-based decision-making. It is the result of market forces, generational drift, and institutional inertia. Correcting it requires the same deliberate effort that any evidence-based practice improvement demands: identifying the gap, understanding its causes, and building the structures necessary to close it.

For the sake of the patients these students will eventually treat, that effort is long overdue.