Malaria: the neverending circle

Virgílio do Rosário A parasite, a mosquito and the man. Malaria has no secrets, but it is still difficult to eradicate. Virgílio do Rosário works on the investigation of this disease in the Centre of Malaria and Other Tropical Diseases in the Institute of Hygiene and Tropical Medicine. A licentiate in veterinary science who, after achieving his doctor's degree, travelled all around the world because of this disease. In this interview, he tells us what he saw and felt in Mozambique, during the floods. How is Malaria studied? Malaria, just like any other disease, has more than 10 fields to work in. One can work only with the parasite, and inside the parasite, there are characteristics referring to it's genotype or genome, to it's virulence, characteristics that only concern the plasmodia. If one doesn't wish to study the parasite, but the patient, then the investigation has to do with the person where the immunity response to the agent can be studied, the infection, the genetics and the pathogeny. There is also another possibility, which is to study people in groups integrated in regions. This possibility is usually related to what is called epidemiology of the malaria or populational studies. Finally, the most important is hardly studied. And this most important is the agent inside the definitive host (the vector mosquito). Obviously, the doctor doesn't look at the mosquito and is not directly interested in it, if he is a clinical doctor. These are entomology studies, or, studies of the mosquito's genotype. Therefore, each field can be focused according to the different phases of the circle. To be able to investigate malaria one should know well the circle and its most important points which are: the vector mosquito, the actual agent and the infected person. Then inside, each of these distinct areas can be studied, but all must be related. A molecular investigator only studies the molecules of the plasmodium. This investigator has never seen a child die from malaria, but knows a series of very important molecules that might be transformed into a future vaccine and that vaccine will stop the child from dying. When the investigator has this molecule purified, he will have to work with other people on field. An investigation is never isolated. We know you were in Mozambique during the floods. What did you feel, as a scientist, and as a person when you were faced with the tragic situation that the people were living in? I don't even know how to answer. I could give you many answers. I'll start by saying that it doesn't make sense that countries aren't prepared for their catastrophes. When there are catastrophes in Azores or Madeira, people have to be prepared for them. If you can remember, there were some, and people weren't quite prepared. Actually they were in part responsible for what happened. They throw all trash into the water exits, stopping the waters from flowing. In Mozambique the tragedy was excessive. The accumulated water was almost the size of Portugal. All countries have their own structures to answer to. They have an army, which can also be used immediately helping as a fire brigade service. But one thing is to say "the catastrophe is so big that nothing can be done" and another one is to state " the malaria will be very serious". Malaria alone is something very serious; maybe the floods made people realize that malaria exists. Concerning the catastrophe, it was so big that it was quite hard to do something immediately. The fact that people were moving from their residences to other places turned all the registers false. People were moving to other places, where there were other registers, and everything got mixed up. If a hospital had a register of all its population and knew how many children had been born and vaccined, the number of malarias, tuberculosis; after the floods nothing is known. When one looks at a situation like this and wants to help, it's a bit difficult. No help is done only by good will and heart . It's a start but it is not enough. Everything has to be done on the basics of money, infra-structures and the places must be prepared to integrate people who come from the outside, so that everyone can work together and there should be some kind of guaranty of continuity. That means that all of the structures must work well, or else the money is badly spent and when whoever is helping leaves everything will remain the same. Catastrophes have to be very carefully analized. You haven't totally answered our questions yet. You didn't tell us what you felt as a person. The fact that malaria still exists in the year 2000 is very sad because everybody knows the circle of the disease. It is known the agent and who transmits it. If there is primary education, if people live in protected houses against mosquito, if there are no tins with water where the mosquitoes can procreate, if all of this happens, concerning education and basic health structures, the cases of malaria will decrease. So, if the disease still exists it's because everyone is a bit to blame. Actually I can tell you that when I entered your school for the first time I was quite shocked by the graffiti on the walls ("animals are not for experiments"). This shocked me more than the floods in Mozambique. I must confess that in Brazil or Africa, I expected to see floods. A graffiti here, I didn't expect. If you had to explain malaria to someone from Mozambique who didn't know this disease (someone from Mozambique or from any other country who didn't know it) how would you explain it? Someone from Mozambique actually knows quite well malaria. He is in contact with it . he knows that the mosquito transmits it. All areas of education, on television and in schools teach people what malaria is and know how it's transmitted. When they have fever, they associate it to malaria and not to insolation. Therefore, people usually associate fevers, headaches and mosquitoes to malaria. They know that there is no need to say a lot. Afterwards they usually go to the local health centre to examine a drop of blood. In that aspect, I think that the people of countries in development know exactly what the disease is. How did the patients react when they knew they had malaria? Were they scared? Not in any way at all. The African population is very used to the possibility of dying. They are not like us. They know that some of their children will die. In Africa people know this. And they have another thing that I have never quite understood well: a great faith in God. They know that when they die it's because God wanted it and they do not bargain for their lives. If someone dies, God decided so. Another curiosity: I have never seen panic before a diagnosis or during the treatment. I have seen pain in presence of death, but that can be seen anywhere, but I never seen panic. Respecting AIDS the situation is probably worse, because the probability of detecting and treating malaria is very big. AIDS prognosis is quite reserved, so... but I've never worked with patients with AIDS. With malaria the situation is different: people go, form long lines and wait hours for the diagnosis from the blades with blood samples to be done. Then they receive the results on a little piece of paper, go to the chemists, where they are given medicine and go home and take it. What is the connection between the floods and the propagation of malaria? It's a bit difficult to answer. It's obvious that the floods will create puddles of water where the mosquito will procreate, but lets not exaggerate this factor, if you go to a part of Africa where there are lots of old tins whit water inside, each tin is dangerous, for it is a source where the mosquito will maintain the infection. Malaria's problem already exists, it exists every year and until now it has not been a system that interrupts the circle of the disease. During the floods, what indications did you give the populations? In first place, the information. In second place, all efforts were made to prevent the contact between the mosquitoes and the population. That also has to do with the education, because if the beds have nets and the children and adults are protect at night, which is usually when the mosquitoes enter the houses to attack the people, the circle will be cut. Education also tells people that there are other processes: the cleaning, hygiene, covered waters to prevent artificial creators. In other words, trying to minimise the use of medicines. The idea of the medicine being efficient is very good, but it costs a lot of money and badly used: used excessively or for to long, it selects parasites that become resistents to him. What has to be known are the habits of the local mosquitoes, to make an idea of the existent parasites and to try to make the daily contact of the village people and the mosquitoes is reduce till the minimum. Only one part of the population shows headaches and fevers. People have different sensibilities. There are always people that have the parasite but have the symptoms. It's like when you say "but you've got the flu and I haven't? why?". There are some people more sensitive than others and, maybe, if I did blood tests on a whole group that lives in a region where malaria exists, I will find 10-20% that have the plasmodium, but for some reason they are not considered sick. The problem is that these don't go to the doctor, they don't need microscopy because they don't feel wrong but they are a reservatory of parasites. So, if you want to cut the circle, you have to destroy the parasites reservatory that is in a person that doesn't show clinical symptoms. The problem isn't so easy to solve. All of this is expensive. It means transport, colouring, blades, bites and treatments. It's a very expensive process. Don't forget that malaria existed in Portugal until the 50's, you did know that, didn't you? Now I ask you: do you know why malaria doesn't exist any more in Portugal?, did the sick people die? Don't plasmodia exist any more? The malaria that existed in Portugal didn't have anything to do with malaria brought by the people from African colonies. Its origin was from local regions in Portugal. Italy and Greece had this malaria like Portugal and Turkey (this one still has some cases of plasmodium vivax). This malaria was different from the emigrants, the tourist that comes from outside, burning with fever. The tourist also has malaria, but he doesn't, transmit it, because the Portuguese mosquito doesn't have the capacity of transmitting the African malaria. But it would transmit quite well the plasmodia that exists here. There is a place in "Águas de Moura", and at that time, if I'm not wrong, it was called Paludology Centre. It was this centre, with the help of American Funds - a very big Rockefeller project - , that did the whole job of irradicating malaria in Portugal. A job like this was done thanks to the financing, with the working of a good structure, you have to always be where the action is and have good data register, so that the work can never be lost and always have a continuity. We know that the Institute of Hygiene and Tropical Medicine concentrates, above all on investigations. Does it do any work on informing the population? The Institute has service called traveller's consultation. Before travelling to countries where there is a risk of contamination, people should go there to ask for information about the risks and precautions that should be taken. Schools in London, Italy and Spain have, on the Internet, according to the Worldwide Health Organization, information about the precautions that should be taken. What is new in the investigations and globally in this area? It's hard to say what's new because we get something new everyday. But, most of the investigation is being done in molecular biology (discovering new molecules), in immunology (how the parasite responds, how people respond to the parasite in his various phases of development: when he enters, when he reaches the liver, when he leaves the liver and reaches the red blood cells) and also serology. Another important aspect is the standarization of the techniques. Some time ago there were no common methods. Today we know that, to determine the areas and people naturally immune to the disease, it is important to bring blood samples of various localities and each investigator studies a sample. If the same protocol is no followed, we will not achieve real conclusions. Did you say that people respond differently to the disease? It must have a significative interplay for the parasite to enter, and has to do with what is called receiver. If the red blood cells doesn't have these receivers, the plasmodium will not be able to make the connection to invade the organism. Therefore, people who don't have receivers, are automatically resistant. The existence of the receiver is very important. But lets turn this question around. Imagine that two of you went on holidays to S. Tomé a lot of malaria exists. You both got there and went to the same places, both where bitten by mosquitoes. When you returned, one of you fell into a coma, went to the hospital and died of malaria. To the other one nothing happened. There are four possibilities: One of you didn't have receivers; You had different immune systems, so the response was different: one of you had a strong response, and defended himself, the other one didn´t; The disease might not have developed; The red blood cells aren't relevant to the development of the parasites disease; By coincidence, one o0f you was bitten by a mosquito that wasn't infected; The one that didn't get sick was prevented and protected. What funds does the institute have? Inside the institute, I work in an investigation centre called Centre of Malaria and Other Tropical Diseases. We are the ones who get the money from the National and European subsides. Our invest8igation is based on projects we elaborate and from which we write asking for money, anyway we can guaranty that money is not in excess or easy to obtain. And are all the projects approved? No, because the world is too competitive. Sometimes we send 15 projects and only two are approved. The scientific quality of young people today, when they finish their course and receive their doctor's degree is very good. A couple of years ago, a student would take eight years to get his doctor's degree. Today, it takes four years. If a student doesn't get it in four years, then he's exceding the limits. Today, scientific life is harder and more competitive. Does the institute form new researchers? We form a lot of them. They can be formed in many ways. For example, here from the city of Torres Vedras, Dinora and Ana entered as investigation probationers or they entered doing the probation of their licentiate's degree (when a student finishes his course, he must do a probation). Usually, candidates to investigators go there to do a probation which takes from six months to do one year. If they are very good, we try to make them stay to get a doctor's degree. We elaborate a project that they must develop, for which we ask for funds in Portugal or Brussels. The Centre does investigations in several different areas not only in malaria. In malaria there is a great discipline in the work; young people don't have timetables, they work during weekends, they have to be fluent, they must know how to write scientific publications, therefore, after a year articles in english. This makes them able to go anywhere on their own. Today, investigation is one of the most competitive areas. And we do not only investigate, we have to give classes and co-ordinate the "Ciência Viva", which gives us quite a lot of work. We have to do a lot of scientific administration, answer letters, contact colleagues, organise meetings which are only to talk, reports, etc. And we invite people from all over, or we take part in the, so called European chains of malaria, where we are associated with tem European laboratories with who we have to meet once a year to discuss things. What are the qualifications necessary to work in the institute? You have to have a licentiate degree. It can be in anything related to scientific nature: biology, pharmacy, veterinary, medicine, bioquimics. I've got a person working with me that had never seen a plasmodium before. It's important to take advantage of the opportunity of having scientists from o0ther areas, it's important to bring people with new experiences to malaria. Don't you ever have holidays? The holidays are reduced. I've worked in the U.S.A., in two places; in Brazil; in Africa and in Scotland, and now I'm working here. When I started in Portugal, I only had a workbench with two microscopes and a small team. Today we have eight international projects and a team of seventeen people, from which thirteen aren't paid by the Institute, they're paid by scholarships or projects. Therefore, keeping a team together isn't easy. Does the work require a lot of discipline? Quite a lot. What has been most difficult for me is the discipline, although I can't complain, I must also talk about the good things. Recently, two young investigators that work with me, wrote a financial report received in Brussels.

Project carried out by Escola Secundária Henriques Nogueira
Backup and scientific revision by Virgílio do Rosário, researcher at Centro de Malária e Outras Doenças Tropicais
Translation by Tanya Vieira (a student in the project). Revision by Gisela Brito