“We are malaria physicians”
“We are malaria physicians” belongs to Tiempos de malaria en Venezuela, a multimedia special published in Prodavinci during 2019.
Image by Roberto Mata / RMTF
Translator: Alfonso L. Tusa C.
They took a blood sample from me, put it in a test tube, and showed me how to examine it under the microscope. This is how I learned to diagnose malaria.
—What’s your name?
—What’s your phone number?
—Who did you come with?
The female patient got up, seated. When Monserrat Barrios saw that raving, she understood that she was in front of a brain malaria case. If the patient fell into a coma, she ran the risk of dying. Monserrat had started two days before an internship as a bioanalyst at Centro para Estudios de Malaria, one of the most important paludism research laboratories in Venezuela. Malaria and paludism name the same thing: an infectious disease that has a cure but kills if it’s not treated adequately and on time.
It was the first time that Montserrat saw a case of serious malaria. She asked the patient to sit down and stay quiet, without knowing how much of the instruction could she understand. She pricked the right earlobe and when the blood drop came out, she pressed a slide against the earlobe until she got three blood drops on the upper part and another onea little bitbelow them. Malaria is transmitted by the biting of the Anopheles mosquito, which inoculates in the blood a parasite named Plasmodium. Montserrat mixed the three drops on the upper side into a circle to see at the microscope if there was Plasmodium in the blood. That diagnosis test is called “thick drop”. Once she saw the parasites, she examined the lower drop, which she had extended on the slide, to corroborate that the patient was infected with falciparum, the Plasmodium’s mortal species. In 2017 there were 435.000 deaths by malaria in the world. Most of them happened in Africa and nearly all the patients died because of the Plasmodium falciparum.
Once she confirmed the diagnosis, Montserrat called her boss, doctor Oscar Noya González, a physician parasitologist who had directed Centro para Estudios de Malaria for almost thirty years. While science defines the parasites as organisms that feed themselves from a human host, Noya saw them as “smart enemies”. Of all the parasites which infect the human being, the Plasmodium was the main enemy.
Once it comes into the body, the Plasmodium flows through the blood, it lodges in the liver, and reproduces inside the red blood cells until they explode. The scientists have debated for years if the first mosquito infected with Plasmodium that bit the man got infected from a bird or an ancestor primate. A study published by the USA National Academy of Sciences shows that Plasmodium falciparum comes from another parasite (Plasmodium reichenowi) which infected the chimpanzees in Africa. An Anopheles mosquito bit a primate got infected and then bit a man, who fifteen days later had shivers, fever, and sweats, a cycle which always evolves in that order and can make collapse organs like the brain.
The Anopheles male and female feed with nectar to absorb sugar and get energy. Only the female sucks blood to catch the proteins they need for their eggs. An Anopheles female lives between seven and fourteen days and lays around five hundred eggs that float as ships on the surface of stagnant waters. When they receive the heat from the sun, they hatch and become larvae. In one or two weeks they get wings, legs, thorax, abdomen, and antennas, inside a capsule called the pupa. When pupa breaks out, an Anopheles is born with the capacity of perceiving the breath, sweat, and body odors of human beings or the animals which will provide them feeding. It distinguishes colors, discriminates warm bodies from the cold ones, and recalls the place where it ate the last time, to get back and look for more food, explains the biologist Fredros Okumu, director of science of the Institute of Health of Ifakara, Tanzania.
Doctor Noya ordered to hospitalize immediately the patient and she got the antimalarial medicine shots. If it doesn’t exist the threatening of death, the treatment is provided through tablets. When the patient recovered her conscience, Doctor Noya asked her if she had been at the Bolivar state. She answered yes. He asked why she had traveled there and she told him that she had worked as a prostitute in a mine. Her husband couldn’t believe what he was listening to.
Venezuela’s gold is extracted in Guayana, so this is the main focus of malaria spreading in the American continent. Amazonas, Bolivar, and Delta Amacuro states integrate this region, the Venezuelan portion of the Amazonia. It’s the greatest potential reservoir of minerals in the world, grounded on the most ancient emerged lands of the planet. Guayana is the modern incarnation of El Dorado, a mythical city that the Spaniard conquerors looked for in South America from the beginning of the sixteenth century. The legend said that a king covered his body with golden dust during a ceremony at Laguna de Guatavita, in the Colombia eastern cordillera, to more of seventy kilometers from Bogotá. The more the colonization process advanced, the dream of a golden kingdom moved to the Amazonia.
The Centro para Estudios de Malaria was in the Ciudad Universitaria in Caracas but most of the patients came from the mines of gold of Bolivar state when Montserrat started her internship, in January 2018. In ten years it passed from being a researching laboratory to an assistance center. In 2007 they received three patients a week. In 2017 they attended forty a day. Luz Marina Mendoza opened the laboratory’s doors at seven o’clock in the morning to collect the patients’ data: name and surname, age, job, visit endemic places. She lived at Valles del Tuy and got up at half-past three in the morning to arrive on time to the laboratory. The bioanalyst took the blood samples and watched them at the microscope. Once they got the result, Noya examined the patient and interrogated him/her to know where he/she had got the disease and if he/she had some condition that impeded to take antimalarial medicine.
If they came from the mines, the women interviewed by Luz Marina said that they worked as cooks, never as prostitutes. To the Doctor, they confessed that came from the “currutelas”, the brothels of the mines. During one consult, a girl told the Doctor that she worked with a friend in a currutela on a Saturday night. The next day her friend wasn’t anymore. When she asked about her, they told her that she had been cut into pieces and her body rests were thrown into a swamp. The girl fled and didn’t know more about her friend. Some patients asked the Doctor how to cure sores in the genitals or alleviate the burning while urinating. Ranellys, a 28-year-old patient who got infected when she was pregnant, arrived at Centro para Estudios de Malaria with her baby in her arms two weeks after the birth. No matter if she had the infection or not, the cousins of the newborn called her Malaria.
Many men said they were driversor merchandisers at the Bolivar state, not miners. They feared that the mines bosses discovered they were giving information at Caracas. They told the Doctor that the treatment against paludism cost “a gram and a half of gold” in the mines, so they preferred to deal with the fever in a bus to Caracas to get the treatment, which the State must distribute for free according to the Venezuelan laws.
Nobody could explain the origin of malaria during four millenniums. It was a plaguethat decimated armies and weakened the farmers of warm and humid regions. In ancient India, they attributed malaria to Takman, the fever’s demon. In Rome, they told that Pope Silvester I had domesticated a dragon that represented the disease. He enclosed it in a cove below Rome, where the dragon breathed a “bad air”. The middle-age Italian scientists transformed the story into a hypothesis that defined malaria as a miasmatic disease, caused by the fetid vapors from the swamps. They called it malaria to allude to the “bad air”, and paludism about the paludis, swamps in the Latin language.
In 1880, the physician and French soldier Charles Louis Alphonse Laverau discovered that a parasite caused the disease when he saw moving flagellum inside the red blood cells in the blood samples of feverish soldiers. At the end of the nineteenth century, the British researcher Ronald Ross demonstrated that the parasite was spread by the Anopheles’ biting, instead of the malign vapors of the swamps. Each one received the Medicine Nobel Prize for their findings. In 1900 the transmission of paludism was so extended in the world that Greenland and Mongoliawere the only countries where didn’t exist malaria.
Paludism was the main cause of death in Venezuela. When Ministerio de Sanidad y Asistencia Social was created in 1936, a third of the population was infected and ten thousand people died yearly. The Congress promulgated Ley de Defensa contra el Paludismo; it’s the oldest current law of the country. The government commissioned Doctor Arnoldo Gabaldón the creation of the first national antimalarial service from the Dirección Especial de Malariología. There wasn’t any experience nor professional personnel to fulfill the task. Gabaldón had to build an institution.
There was malaria on the coast, the valleys of the Mountain range, Guayana, and the Plains, where the number of people who died was higher than people who were born. The states without paludism were “islands” in a “malarial sea”, Gabaldón said. The physicians found three species of Plasmodium in Venezuela: vivax, the most common in the world; falciparum, which can cause death and malariae, the less frequent.
The malarial patient stayed limp, confined on a bed. The families in the country died of starvation because no member of them could work. The life expectancywas of thirty-seven years. In one of those journeys, one patient told Doctor Enrique Tejera, the first minister of Sanidad in Venezuela, that he lived in a town of watery blood: clear, weakened, and disembodied, after the Plasmodium destroyed the red blood cells.
The central command of the antimalarial fight was installed at Maracay, in a colonial-style building that Doctor Gabaldón ordered to construct. To operate in an endemic city gave Malariología legitimacy through the example. Gabaldón designed courses to train urban and rural visitors in the malaria diagnosis, he built a department of sanitarian engineering and convoked the citizens to deliver quinine voluntarily.
The quinine is the main component of antimalarial medicines like primaquine and chloroquine. Quinine comes from the word quina, which means “bark” in the Quechua language. . The Incas in the Peruvian Amazonia discovered that the quina tree’s bark cured the fever and called it quina-quina, the bark of barks. The Englishmen added soda to the quina and created gin tonic to prevent paludism. Winston Churchill said some time that gin tonic had saved more English lives and minds than all the physicians of the empire. The artemisinin is a fundamental compound to treat Plasmodium falciparum. Under a program on research created by Mao Zedong in the 1960s, the Chinese scientist Tu Youyou discovered that the Artemisia annua herb destroyed falciparum. In 2015 she won the Medicine Nobel Prize.
Beginning in 1945, Gabaldón sprayed the malarial zones houses with dichlorodiphenyltrichloroethane or DDT, an experimental insecticide produced in the USA. After the Anopheles’ biting, it sits on the walls and urinates the liquid part of the blood to lose weight and keep flying. DDT impregnated the mosquito’s legs, damaged its Nervous system, and killed it. That’s how they cut a millennial biological cycle. This strategy brought malaria transmission to a historical minimum at the end of the 1950s. In 1961, the WHO certified Venezuela as the first country that eliminated malaria in a territory bigger than four hundred thousand square kilometers, before than the USA, Europe, and the Soviet Union.
Malariología centralized the vigilance and epidemiologic control of paludism in Venezuela. Being a tropical country, with ideal temperatures for the mosquitoes and parasites reproduction, it forced to monitor the outbreaks continually. When the Venezuelan people stopped getting ill and of dying of paludism, they began to study, plow (seed) and work in the oil industry. To defeat malaria helped Venezuela to come in the modernity.
The mining threat.
Malaria’s outbreak in Guaniamo, the biggest diamond deposit of Venezuela, cited in Bolivar state, was the first caution that the mining could complicate the control of the disease in the south of the country in 1970. Then, Gabaldón said that malaria in Guayana was “inaccessible” due to the difficulties to penetrate the jungle and arrive at the sick persons. That year, the State founded Minerven to industrialize the production of gold and operate the El Callao’s municipality deposits in Bolivar state.
After about sixty years of exchange rate stability, the first devaluation of the Bolívar currency in 1983 opened a stage of poverty’s upsurgeand changed the endemic map of Venezuela. Many people trusted in the fantasy of easy money through the extraction of gold and went to work in the open sky mines in forest and jungle zones plagued by Anopheles. In little time, the malaria of the mines extended through Bolivar state and multiplied the spreading to thirty thousand cases. A record number. The transmission increased to 157%, between 1987 and 1988. That year the state government, Ministerio de Sanidad y Desarrollo Social, and Corporación Venezolana de Guayana (CVG) signed an “Antimalarial Agreement” to cooperate with the epidemics contention. The Bolivar state’s miner industry couldn’t advance if its workers got ill with paludism. Four years after signing the agreement, transmission decreased by 53.6 %.
An attempt of an antimalarial vaccine.
Doctor Gabaldón founded the Centro para Estudios de Malaria in the 1970s to research on the infection in birds after he retired from public administration. There he worked with Doctor Noya, who had studied a doctorate in Tropical Medicine and Medical Parasitología at Louisiana State University in the USA. He studied pre-grade at Escuela de Medicina Luis Razetti of Universidad Central de Venezuela.
Nearly his eighty years, Doctor Gabaldón looked for new ways of fighting malaria while mining grew up in Guayana. He proposed Doctor Noya to invite the Colombian immunologist Manuel Elkin Patarroyo, director of Instituto de Inmunología de Colombia, as a lecturer of Congreso Latinoamericano de Infectología to be held at Caracas, to present the SPf66, the first antimalarial vaccine made chemically (synthetic), which had reported positive results in experiments with apes and soldiers of the Colombian army. In an auditorium at Hotel Caracas Hilton, Doctor Gabaldón listened carefully to him in the first row. Patarroyo told how he had created the vaccine, how he had tested it in “owl apes” (Aotusnancymaae) at the Colombian Amazonia, and how they had started clinical trials with Colombian soldiers that showed the vaccine’s harmlessness and efficacy to prevent the spreading. As the Colombian Ministerio de Salud hadn’t authorized Patarroyo to test it in civil persons, at the end of the presentation, Doctor Gabaldón proposed him to do it in Venezuela and invited him to a meeting next day, at nine in the morning.
Before going to the interview, Patarroyo asked Noya to take him to the Panteón Nacional. He admired Simón Bolivar and wanted to know his tomb. Noya told him that they had to be brief: Doctor Gabaldón didn’t forgive unpunctuality. They were fifteen minutes late and Noya feared that the meeting could get frustrated because of that fault. Patarroyo justified on Bolivar and Gabaldón answered serious: “If you went to visit that Sir, I forgive you”.
Gabaldón and Noya traveled to Bogotá and visited the Instituto de Inmunología of Hospital San Juan de Dios, where Patarroyo worked. During the first visit, Doctor Gabaldón felt indisposed after lunch. That afternoon he went to the hotel, instead of going to the laboratory. When Noya and the Colombian doctor Roberto Amador went to see how he was feeling, the room smelled of ammonia. It was what is denominated as uremic breath, a symptom on that Doctor Gabaldón’s kidneys weren’t processing the toxins expulsed in the urine. They got back to Caracas and Gabaldón was hospitalized for one month and remained unconscious.
Doctor Gabaldón didn’t watch the vaccination sessions that started on August 25th, 1989 in the population of Guarataro of the Majadas municipality, to the Northeast zone of Bolivar state, inhabited by farmers who began to get ill of malaria. That study was the first evaluation of a vaccine against malaria in a civil population and the first trial with a synthetic vaccine that gave an efficacy of 55% for the Plasmodium falciparum and 41% for the Plasmodium vivax. It was the first international research project that Noya coordinated. “After testing the SPf66 in 20.000 patients in the American continent, Asia and Africa, it was proved that the vaccine didn’t reach the expected efficacy, but it set the bases on the field studies designs for the future vaccines against the disease”.
After Gabaldón’s death on September 1st, 1990, Noya assumed the direction of Centro para Estudios de Malaria.
Beginning with the trials with SPf66, during the 1990s doctor Noya looked for asymptomatic patients on the Northside of Bolivar state, that is to say, people infected with Plasmodium that didn’t manifest any symptom. But he didn’t find them because they used to appear in zones of high spreading, where patients develop certain immunity grade against the parasite and stop showing symptoms after infecting many times.
The asymptomatic patients are important because they transmit the parasite to the mosquito. As they don’t feel the malaise, they don’t go to consult with the physician, don’t get any treatment and infection propagates. In previous studies, it had been found a relation of four to six asymptomatic patients for every patient who had symptoms. In 2017, Venezuela registered 53% of malaria spreads in the American continent: 411.586 cases. If the number of infected people in 2018 was similar and the asymptomatic patients are added, the calculus could arrive at 2.8 millions of infected people who would need antimalarial medicine in 2019.
Doctor Noya thought that the only way of stopping the spreading at endemic areas was treating everybody: the ones who had symptoms and the ones who don’t. He wanted to show to the government that he had to count in his statistics the asymptomatic patients and no only the ones who got infected for the first time. Bolivar was the state with the biggest malaria transmission in Venezuela since 2003, the ideal place to look for them.
The centralized system of epidemiologic vigilance constructed by Gabaldón was dismantled during Hugo Chavez’s government, regrets Noya. The monitoring and attention to outbreakswere distributed among the regional directions of the environmental health of Ministerio de Salud and the states’ governments, although the transmission doesn’t respond to frontiers but an epidemiologic effective control. The situation was aggravated during the times of the Arco Minero, a Chávez initiative rescued by Nicolás Maduro in 2016 to operate the Guayana’s minerals. That year, the Ministerio de Salud stopped providing antimalarial medicine to the Centro para Estudios de Malaria. The treatments are donated by the Panamerican Health Organization (Organización Panamericana de la Salud) (OPS) and international ONGs. From 2008 through 2017, the malaria number of cases in Venezuela increased 1.185% according to statistics published by the
BoletínEpidemiológico and World Health Organization.
During an allocution on March 26th, 2018, Maduro showed a little plastic bag that contained some blister and a paper which said:
“Nicolás Maduro conductor of victories. Antimalarial treatment totally free.” He recognized that “the mine’s operation in Bolivar state” had created “malaria serious problem” and said that the Bolivar state’s governor, the National Guard general major Justo Noguera, was “in charge of this battle by the health.”
The OPS advises Venezuela in the national program of malaria’s elimination. ´The prologue of treatment guidelinesof 2017 says: “Because of the persons’ movement on the Arco Minero, coming from different states and frontier countries, the risk of malaria transmission has broadened to the whole country.” The document is distributed among physicians in the endemic zones and recommends early diagnosis and complete treatment, the World Health Organization’s recipe for all the countries. That’s why the OPS provides medicines, laboratory material, and nets impregnated with insecticide to Venezuela.
In Guayana’s mines, many factors are combinedto favor the transmission. The mosquito reproduces where miners deforest, biologist María Eugenia Grillet explains, researcher of Instituto de Zoología y Ecología Tropical de la Facultad de Ciencias of UCV. When they find gold, they take out from the land its vegetal protection and leave lagoons and ponds which get hot under the sun without any shadow from the trees. The Anopheles females have more space to deposit their eggs, more miners to feed with and more parasites that infect them when they suck blood. The birds and mammals emigrate when vegetation disappears, so indigenous peopleand miners are the only sources of feeding for the mosquito.
When poverty increases, more people go to the mines the malaria’s cases increase in the miner municipalities of Guayana, as it happened in the 1980s after the economic devaluation. The new miners are immunologically naive because they have never infected with Plasmodium and therefore don’t have a defense to counterattack the infection. They don’t get all the antimalarial doses nor dispose of nets impregnated with insecticide in the mines. When they get back home, many miners sow, according to the malariologists, “the malarial seed”: they carry paludism to states where it had been eliminated in previous decades. The local Anopheles bites the patient infected at Guayana, they got infected and transmit the disease to persons that haven’t been at Guayana. Those patients are called native cases because they got infected in their original place. In Caracas, there isn’t any transmission because it’s a valley and the topography doesn’t favor the Anopheles nurseries, but in Valles del Tuy, seventy kilometers from the capital city, there is paludism.
The malarial seed disperses on the American continent. Venezuelan scientists and from Glasgow University said that epidemics could propagate around South America due to the Venezuelans who migrate while being infected with diseases as malaria, in a study published in February 2019 in the medical magazine The Lancet.
The expedition to Tumeremo.
Driving a station wagon Chevrolet of Centro para Estudios de malaria, Noya traveled in December 2018 to Bolivar state along with Albina Wide and Rosa Contreras, professors in Escuela de Medicina Luis Razetti. Albina was a biologist; Rosa, bioanalyst. Together, they had visited paludism endemic zones for more than thirty years. Montserrat, a newly graduated bioanalyst, was the new integrant of the team. She participated for the first time in fieldwork with her masters.
Doctor Noya carried his personal computer to make a presentation of 80 slides to physicians and microscopists of Tumeremo. The next day, Noya and his team dictated workshops to microscopists. Many of them were inhabitants of the indigenous towns and far away communities who were trained by Ministerio de Salud to diagnose paludism and solve the lack of sanitarian personnel in inhospitableregions.
Doctor Noya showed them samples of parasites difficult to identify for practicing. He was proud of Luis Peterson, “the best microscopist to the South of Orinoco”. Once he showed Peterson a slide of ovale, a Plasmodium species that exists in Africa, not in the American continent.
“Doctor, it isn’t falciparum, nor vivax, nor malariae. I know it doesn’t exist in Venezuela, but I would say that is an ovale”, Peterson told to Noya with his eyes glued to the microscope. Non-student of the PosgradoNacional de Parasitología in Caracas had approved that test.
The microscopists told that in the zones of higher spreading, they saw from 100 to 150 samples of blood daily, although the bioanalysts of Ministerio de Salud recommended them don’t examine more than 70 to avoid that tiredness led them to give the wrong diagnosis. The Ministerio didn’t give them methanol, nor colorant to fixate and differentiate the species of the malarial parasite in the field. Worried, they asked how to overcome those limitations. Doctor Noya told them that during 2018 they hosted 56 patients in Caracas, those patients had gotten infected in the mines with Plasmodium malariae, but in the local reports, they never found that species. It demonstrated failures in local diagnosis.
Between 2017 and 2018, they saw for the first time cases of triple malaria in Centro para Estudios de Malaria. Patients that had Plasmodium vivax, falciparum, and malariae at the same time. The patient is bitten by a mosquito infected with the three species or several mosquitoes infected with each one. Triple malaria indicates that the parasitical charges are out of control.
At a conference before the sanitarian personnel in Tumeremo, Doctor Noya remembered them that the fight against malaria is an alive gear thanks to the teamwork of physicians, bioanalysts, microscopists, nurses, researchers, and drivers. They wake up very early to arrive at the mines through swampy roads, don’t eat during the operatives at faraway communities, and assume the risk of getting infected if the journal extends until dusk at spreading zones. The doctors, otherwise, talked about the dilemmas associated to work at the mines.
—If the salaries the Ministerio de Salud pays us aren’t enough to eat, can we accept that the armed groups pay us with gold or dollars? — A physician asked.
—Are we going to leave them to extort us? — Another one replied.
A Doctor told an anecdote:
—I have good and bad news for you, doctor — A microscopist told her.
—The bad one at first —The Doctor answered.
—The delinquents don’t want you.
—And the good one?
—The guerrilla does want you.
Noya’s team collected more than 300 samples of blood and urine of asymptomatic patients. From the test tubes through the reactants and quick tests they used in the expedition were donated by an international ONG installed in the countries where there are humanitarian emergencies. Before leaving Tumeremo, they stored the samples in refrigerant boxes to preserve them intact until Caracas and charged them in the station wagon’s cabin. Afterward, they would make molecular tests on the parasites. In the space that remained free, they placed their luggage, a projector, and boxes of antimalarial medicine for around 200 patients.
The night before returning to Caracas, they slept little. They worked until very late at night to organize the samples and left from Tumeremo before five o’clock in the morning. The roads became more dangerous after midday. But the station wagon’s breaks got broken leaving Upata and they had to look for a mechanic at the side of the road. The man spent the whole morning repairing the failure.
When they rode on the road of Uverito, at the Southside of Anzoategui state, they got shot from a Grand Cherokee station wagon. It was beyond four in the afternoon. He bioanalysts shouted and the doctorspun the steering wheel to the left. The assailants, hooded, got ahead, treated on getting them out of the road and the two station wagons clashed. The hood of the Chevrolet one smoked. The hooded guys got off, hit the windows, and opened the pilot’s door. They pulled the doctor by the shirt, kneeled him, and aimed him to the head.
With his hands up, Noya looked at the flip-flops and the stained with dirt feet of the assailantwho aimed at him. “We are going to kill you”, he said. Other four gunmen aimed at the women who were inside the station wagon. The road was desolated. When they saw Noya in front of the gun, the professors thought they were going to kill everybody.
The assailants raised the physician from the ground and pushed him inside the station wagon. One of the delinquents took the steering wheel, another one sat at the co-pilot’s seat and the two vehicles came into the Uverito forest.
—Where is the gold? —the copilot asked aiming at the passengers with the gun
—We are malaria physicians. We don’t have any gold— Noya answered.
—If you have a gun hidden in this shit, we kill you — the copilot answered while shuffled the glove compartment.
They stopped at anopen space and ordered them to lay prone on the floor, while the assailants plundered the station wagon. One of them told Monserrat that he would throw the keys on the floor, near the left forward tire. They started the Grand Cherokee and left.
The doctor and the bioanalysts got up and verified that nobody was hurt. They robbed the cellular phones and bags and wallets. They checked the cabin, the delinquent had taken the luggage, the boxes with the 200 treatments of antimalarial medicine, and Doctor Noya’s computer. They didn’t touch the refrigerant boxes, the test tubes with the samples of the asymptomatic patients were intact. The study had saved.