Interview with Quim Gascon: “My Research Has Always Been Triggered by Questions that Came Up When I Was Treating Patients”

Quim Gascon, co-director of ISGlobal’s Chagas initiative, looks back on his long career, from his early work in Rwanda to his current commitment to the problem of Chagas disease.

Quim Gascon is one of the veterans in ISGlobal. He started his career in 1989 in what was then the Tropical Medicine Service of the Hospital Clínic in Barcelona, which had only recently been set up by Dr Manuel Corachán. Together, they started on a journey that subsequently, with the arrival at the hospital of Pedro Alonso and Clara Menéndez, led to the creation of the Barcelona Centre for International Health Research (CRESIB) and eventually ISGlobal.

Gascon sees himself as a man of action, as someone who likes to ask questions. And that is what he has been doing since he ran a hospital in Rwanda just a few years after completing his medical studies. His work with patients there led him to ask questions. He wanted to find solutions to the problems he saw that affected the community. This impulse led him to take his first steps in research.

He admits that when he retires he is going to miss the exercise of this intellectual curiosity that pushes him to always think outside the box. Having just turned 70, he is putting the final touches to a plan to ensure the continuity of all the efforts he has led. He says he is in the process of “letting go”. We interviewed him on his return from one of his trips to Gran Chaco in Bolivia, where ISGlobal is working with the SANIT foundation to improve the quality of life of the country’s most vulnerable populations.

- Did anyone ever talk to you about Chagas disease in medical school?

- Very little. I completed my training in 1978 and it wasn’t until 2003 that I had to pick up a book to find out more about how Chagas disease worked. Life takes many turns and you never know when a door will open and lead you to another task, another idea.

- What medical speciality did you choose?

- I did Internal Medicine and from 1982 to 1986 I worked in Rwanda managing Nemba Hospital as part of the organisation Medicus Mundi. On my return to Barcelona, I started working at the Hospital Clínic with a grant. For a few years, I was also very involved in Medicus Mundi and was president of the organisation in Catalonia. So my professional activity was focused on the field of tropical medicine as it was conceived of then.

- At that time, after the death of Franco and during the transition to democracy in Spain, were Spanish doctors already working in what was then called “the Third World”?

- Not many. My references were Dr Salvador Cortadellas, who had spent time in Africa and was one of the founders of Medicus Mundi, and Manuel Corachán, who worked for a long time in a number of different African countries and in Papua New Guinea before going to the Hospital Clínic in Barcelona. He had also been the director of the University of Barcelona-Hospital Clínic course in Tropical Medicine that I had taken.

Rwanda 1982

- Did your experience in Rwanda have a lasting influence on your life?

- Yes, it was my first experience in tropical medicine in an African country. The four and a half years I spent there and everything I learned working there have shaped my life since, and not just professionally.

- What did you find there?

- At that time Rwanda was known as “the Switzerland of Africa” because it was a very mountainous country (“the land of a thousand hills”) and it was small and quite peaceful internally. There were, however, a lot of problems, most of them common to all African countries, including the precarious structure of its health services. I went there at a very interesting time in the history of public health: in 1978, the World Health Organisation (WHO) had approved a strategy for primary health care.

- What were the main points of that strategy?

- The WHO declaration talked about upgrading and modernising health systems everywhere; it proposed concrete strategies for immunisation, community care and community participation in identifying the health problems that needed to be addressed in the area. It also made the point that countries had to face up to their own health problems and should seek innovation in both objectives and methodology rather than conforming to the directives of the centres of power. It also dealt with issues that were not strictly health-related, such as the economic model. There was a whole strategy for building a health system from the base upwards, especially in the most isolated places, starting at community level and building on that to finally create what we would call tertiary referral hospitals. In general, everything that today we would call development. And the strategy was informed by a very political and social point of view. Today we have the Sustainable Development Goals (SDGs). Well, that declaration was similar but had more depth and more political charge.

Photos: ISGlobal.

- It was never implemented…

- Very soon after the strategy was approved, opposing voices started to emerge. These included important figures, including a member of the Rockefeller Foundation who published a supposedly scientific article saying that implementing the strategy would be very difficult and that he was therefore proposing a sustainable “selective primary health care” model. But opposition did not come only from the world of academia. In some countries where people tried to implement the strategy, the community leaders who had taken the WHO declaration seriously and put it into practice were assassinated. In the end, here in Europe primary health care is the term used to refer to the first line of care for the population and on the international level the only aspects retained have been immunisation campaigns and little else.

- But in 1982, when you went to Rwanda, there was hope that things could be changed.

- I was hopeful when I left Spain, but when I arrived at the hospital in Nemba what I found was an institution closed to the world around it: the hospital was treating patients who came through its doors but nothing was being done outside, in the community. I also found an organisation in which all the leadership positions were held by white people. My proposal was to open the hospital and take it into the community. For example, we were dealing with one epidemic after another (dysentery, cholera, amoebiasis) because the people were drinking contaminated water. And it is all very well to care for sick people, but it is also important to ensure, whenever possible, that people do not get sick. We implemented a programme to fix more than 300 community water sources situated within the hospital’s direct area of influence. Then we did the same thing with vaccination campaigns—we went outside the hospital. And with medical workers in schools and traditional midwives, who we trained in the prevention of uterine ruptures and neonatal tetanus, a common problem at that time. At the same time we encouraged the Rwandan staff to gradually move into leadership positions in the hospital.

2018. Photo: ISGlobal.

- Was it in Rwanda that you started doing research?

- Yes, that was where I took the first steps along that road. For example, one of the things we observed was that there was no malaria in the region served by the hospital. It was situated at a high altitude and was isolated by natural barriers from areas where mosquitoes were endemic. All of the cases of malaria we treated involved local people who had returned from working for weeks or months in parts of the country where malaria was present.

We never encountered cases of malaria contracted locally until after the construction of a new road that passed close to the hospital. It was a wide, paved highway that connected the capital, Kigali, with Ruhengeri, the capital city of the north. The construction involved clearing a lot of forest and flattening hills, which opened up a route for the mosquitoes and eliminated the natural barriers that had previously prevented them from migrating and extending their range. Not long after, in Nemba hospital, we started seeing the first cases of malaria contracted locally. How did we know that these cases were local? It was obvious because we started seeing children with malaria, and the children had never gone to work in Kigali or anywhere else. Around the same time, we also started to encounter chloroquine resistance. In those days, chloroquine was used to treat malaria so this led us to undertake research aimed at finding a solution to that problem. My research has always been triggered by questions that came up when I was treating patients.

Problems Challenge Us to Improve

- At some point you decided to return to Spain.

- Yes. I completed two contracts back to back, but it wasn’t easy. The process of extending the hospital’s activities into the community was accepted by everyone, given its excellent results. But the “Rwandisation” of the hospital (getting Rwandans into leadership positions) was not so well received and, for some people, was hard to swallow. That might have been why I decided that my job there was done and that it was up to other people to continue the work.

- And have you been back to Rwanda?

- Twice. Once in 1994 to work for a few months in a refugee camp in the Bukavu area (Congo) after the war, and again fifteen years ago to see how the country was doing in the region where we had worked and to visit friends and acquaintances who were working there.

- Is the hospital still there?

- Yes. Today, it is part of the country’s public health network.

-And has the Rwandan health system evolved?

-Well, you have to bear in mind that a lot of the healthcare infrastructure and organisation was destroyed or damaged during the war in 1994 and that many people working in the field were killed. Socially, things have not changed a lot: there is an affluent class in the capital, which is a magnificent showcase for the current government, but the dynamics in rural areas are much the same as they were all those years ago. And the economic gap between these two worlds is now much more evident than it was before. The health infrastructure has been rebuilt but is similar to what was there before, with a bit more resources and health personnel.

- Is it discouraging to see that the years go by and the problems persist?

- Yes, but that is also an invitation to think about how things could be improved.

Chagas Disease: Starting Again, Almost From Zero

- And in Bolivia? Have you also seen improvements since you started working there?

- The Rwandan project was much more holistic and change was visible within a short period. Our work in Bolivia is related to a single disease and takes place within the framework of a national health system with all its own routines, so it is more difficult to see the changes. However, the diagnosis and treatment of Chagas disease has increased dramatically.

Bolivia, 2016. Photo: Ana Ferreira / ISGlobal.

- Chagas disease is endemic in parts of Latin America and is one of the world’s most significant neglected diseases, no?

- Yes, in fact the WHO has included it on a list of some twenty-odd neglected diseases in the world. This neglect is due to many factors. One is the prolonged interval between a person being infected and developing symptoms (20, 30, or even 40 years), which makes it difficult to connect cause and effect. Physicians very often do not realise that a patient’s cardiac, neurological or digestive problems are caused by this parasitic disease. Secondly, not everyone infected with the parasite develops symptoms. In addition, even though the first drugs for its treatment were developed in the 1960s, until relatively recently Chagas disease in adults in Latin America was rarely treated. Children were more likely to receive treatment, but even that was uncommon. The main aim of the project we participated in was to set up platforms to provide comprehensive care for adult patients with Chagas disease. The project also delivered continuing medical education to health professionals concerning the disease and developed protocols to help them provide care for those affected.

- Is the disease more visible today in Europe?

- A bit more. Raising its visibility has been difficult because Chagas disease is not very common in Europe and most of those affected are immigrants. In Spain, the European country with the largest population of immigrants from Latin America, we estimate that between 50,000 and 70,000 people carry the parasite. In other countries, the case numbers are much lower and the authorities have been slower to take action. For example, two years ago we collaborated with professionals in Germany to develop guidelines for the care of patients with Chagas disease. It’s been years since we did that here, back in 2007-2008! But we are making progress, little by little.

Chagas disease Conferences 2023, Barcelona. Photo: Aleix Cabrera / ISGlobal.

Asking Questions

- How did you first get interested in Chagas disease?

- First, the blood bank at Hospital Clínic detected Chagas disease in a person who had come from Bolivia and then the hospital’s travel health service attended a patient with a heart condition that turned out to be caused by Chagas disease. That happened in around 2003. Spain had started to receive a large influx of migrants from Latin America so we had to ask ourselves a few questions. Are these isolated cases, like what we see with other tropical diseases? Or are they the tip of an iceberg indicating a public health problem that we may be facing in this country? Together with Dr. Montserrat Portús, professor at the University of Barcelona (UB), and her group, we started to investigate the question and obtained the following answer: there were a considerable number of Latin American people with Chagas disease living here, particularly Bolivians, and our results made it clear that this did, in fact, represent a new public health problem. The insect vector that transmits the parasite is a bedbug that does not exist in Spain, but there are other routes of transmission, such as from mother to child and via donated blood or organ transplants. This means that people here can be infected through those alternative transmission routes.

- So what did you do next ?

- Working with the Department of Epidemiology of the Catalan Government, we designed a programme to control the transmission of Chagas disease from mother to child, which is still in operation in Catalonia. We also worked, together with other institutions, to make it compulsory for blood banks to test blood samples for Chagas disease and we started to raise awareness about the disease and develop protocols to monitor its possible transmission via transplants. At the same time, we realised that, since most of the people detected with Chagas disease came from Bolivia, maybe we should do something in Bolivia with Bolivian colleagues. And that was the seed that gave rise to all the activities and all the projects we now have in Bolivia. Some of those involve working within the Bolivian health system and others are research projects that follow the same lines of research that we have been developing here (clinical trials, biomarker research, etc.)

- So all of your work is the result of the questions you ask yourself?

- All research stems from the questions we ask ourselves. Why are we diagnosing Chagas disease in Barcelona? Are there more people out there with this disease? What are the possible implications? What might the impact of that be in our country? And so on. In Rwanda it was the same: we had one epidemic outbreak after another of diseases that we knew were waterborne. So we had to ask the appropriate question, no? We had to find out why that was happening. And once we found the cause, we had to find a solution. In Rwanda the solution was to organise the drinking water sources, create new ones and ensure that they were all safe and protected from contamination. My research stems from my work on the ground, from what I see happening in a community or a group of people.

Bolivia, 2016. Photo: Ana Ferreira / ISGlobal.

- What questions are you asking yourself now?

- The first questions we asked about Chagas disease were very epidemiological and clinical. As you delve deeper, you realise that the problem is much broader than that and related lines of research have been emerging gradually. For example, research on biomarkers of therapeutic efficacy. We treat patients because we know that the drugs have a certain efficacy, but in adults this is not 100%. However, we have no test or clinical sign that can tell us whether or not we have eliminated the parasite. It would be nice to have a tool that would enable us to tell a patient after their treatment “Hey, you are clear now, the problem is solved” or “We haven’t solved this yet and we’ll need to do more tests or change your treatment”. Finding new biomarkers and new drugs are two of the lines of research that we are currently pursuing because they are important in the context of patient care. We are also looking for new tests to facilitate the early detection of Chagas disease in newborn babies because the current tools are rather mediocre or difficult to implement in certain places where the disease is endemic. Newborn infants can be treated and, in this case, we do have the tools to confirm that they have been cured. These are problems that need to be researched and the solutions won’t be found overnight.

Professional Status: Letting Go

- You may not be around to see those solutions?

- I might be if I last till I’m 90 or 100 years old! But I know that other professionals will follow these lines of research, at ISGlobal and around the world.

- How do you feel now you are winding down your professional activity?

- I am currently in the process of letting go and involved in what we in ISGlobal call “succession planning”. Older researchers are responsible for organising the continuity of the team and the lines of research. I am putting the final touches on my plan and it is not causing me any problems. I think it is the right thing to do and I am happy because there are excellent people coming along behind me.

- What will you miss most?

- As a professional, I will certainly miss the research. It is so exciting. In research, you have to be thinking all the time, communicating with other researchers and discussing the best way to move forward. The task is mentally challenging and stimulating. And it is fun. But the best way is to let go gradually to minimise the final shock. And that’s why I am also preparing myself for the challenges I’ll face in the next phase of my life, which will stimulate me to keep on thinking, communicating and living actively.