A few years ago, aged 22, I had the privilege of working with a team from the Philippine Research Institute of Tropical Medicine, on Plasmodium knowlesi – a malaria species of rhesus macaques that was identified in the 1930s. In 1956, P. knowlesi was identified in a U.S. army veteran who had served in Korea. It was thought to be an isolated case. However, since 2004, work by Malaysia-based researchers has shown that the parasite is a major cause of malaria in South-East Asia.
The job of the team that I was working with was to conduct preliminary studies on the prevalence, source of transmission, and distribution of P. knowlesi, relative to other malarias, within the human population of Palawan Island in the Philippines, an area with a constant rate of malaria transmission that had previous reports of P. knowlesi in human patients.
The adjustment phase
At the time of working in the Philippines, I was contemplating a medical career with Médecins Sans Frontières and I thought that my experience in the Philippines would be a good taster of life as a nomadic medic.
The reality of living and working in a developing country was anything but a straightforward transition. I had been transported into the tropical rainy season, which brought with it plentiful and massive insects that became my roommates, even taking up residence in my humidity-chic Diana Ross hair. Add to this, an adjustment to having water cockroaches as roommates, running from stray and potentially rabid dogs on an almost daily basis, and a need to use questionable-looking squat toilets – the last two are great workouts by the way. On that last point, it’s a given that if I could recommend a single luxury item to take on such an expedition, it would be Imodium.
The harsh realities of fieldwork
One of the first things that we had to do was to obtain permission from local government officials to conduct work in specific areas. At the time, Palawan Island was beginning to be marketed as an eco-tourism destination; tourism contributes ~500 billion Philippine Pesos (an 8% share of total GDP) to the Philippine economy, and it is understandable that officials may have been concerned about the findings of our study.
Following the approval of local officials, we set up basic clinics in different remote locations every day over a one month field project. Every day, a team member would phone ahead to alert health workers in a target destination of our arrival, and ask them to recruit volunteers. We spent long days collecting blood samples from every individual who attended our clinic, and often worked into the night using only head torches, as electricity was scarce. The team was split into groups for weighing individuals, taking their temperature, questioning them about using mosquito nets, diagnosing malaria using rapid diagnostic tests and microscopy, and collecting blood samples for testing in Muntinlupa City. This work is exceptionally tiring, especially when you rely on the goodwill of translators, and when you are on your feet for most of the day. In total, we ended up collecting ~3,000 samples from donors aged 10 months to 66 years. We didn’t find evidence of P. knowlesi infections in human populations, but P. falciparum and P. vivax were common.
An aspect of fieldwork that I found the most difficult was that the vast majority of patients who attended our clinics did not have malaria; the most common problems that we encountered were malnutrition and heavy worm infections that caused regular blood loss and stunted growth, all of which were predominantly seen in young children. All we could do in these situations was to recommend that the patients visit larger, well-equipped medical centers, which is nearly impossible for destitute populations who live in remote locations. In situations like these, it is difficult to maintain morale.
A particularly challenging time was when I, unintentionally, became something of a method parasitologist after contracting non-hemorrhagic Dengue fever, a heavy worm infection, and amoebic dysentery – all at the same time. Acquiring tropical infections isn’t something that is new to me – I acquired horse fleas at the age of 2 after hugging a horse, leading my mother to have to take me to a vet for treatment because “human doctors didn’t have the appropriate animal shampoos in stock”. Thankfully, I didn’t need animal shampoo in the Philippines and made a full recovery from all three diseases.
My experience in the Philippines changed me in a lot of ways but most significantly it changed my mind about pursuing a medical career. I know a lot of doctors who work in disaster regions and have a lot of respect for them. For me, however, the experience felt like putting a plaster over a wound that just wouldn’t heal. Instead, I decided to pursue a research career and look at alternative ways of approaching infectious diseases and healthcare in the developing world. I have since moved into scientific publishing but have maintained a very strong interest in infectious disease genomics, including editing an entire Genome Biology issue dedicated to this topic.
On reflection, the amount of funding that has been allocated for infectious disease research has significantly increased since 2008. However, there remains the essential step of translating the research into practice in endemic regions, and it is not certain how well this can be done. One of the most important lessons that I learned is that malaria is just one of many devastating diseases that affect millions around the world every year; its eradication would need to be the beginning of a wider strategy for disease control across the globe.