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Editor-in-Chief
BRAZIL: DENGUE TOLL HITS 92 IN RIO STATE
The death toll from a dengue outbreak in Rio de Janeiro state has reached 92, topping what was previously the state’s deadliest bout with the disease, Brazil’s government news agency said Wednesday. Another 96 possible dengue fatalities have been reported in the current outbreak but have yet to be confirmed.
Washington Post, April 24, 2008 (1)
Meanwhile, Rio Mayor César Maia, recently on the road in northeast Brazil, prayed to a local [Macumba] god to carry the dengue mosquito out to sea.
Newsweek, April 14, 2008 (2)
"Yes, sir," [replied the Negro to Candide] "When we work in the sugar mill and get our fingers caught in the grinding machine, they chop off our hand; when we try to run away, they cut off a leg. That cost me an arm and a leg: it’s the price of your eating sugar in Europe! And yet when my mother sold me for ten silver pieces on the coast of Guinea, she said to me, ‘My dear child, bless our local Fetish gods; worship them forever; they will make you happy; you’ve been given the honor to be a slave to our lords, the white folk."
Voltaire, Candide, 1759 (3)
DENGUE IN BRAZIL
In the most severe epidemic ever to sweep the country, nearly 230,829 Brazilieros came down with dengue fever between January and April of this year. As the death toll from dengue and dengue hemorrhagic fever neared 100, Brazil’s minister of the Health, Jose Gomes Temporão, conceded that the country has "lost its war" against the disease, which had also broken out in 1986, 1995, and 2002. He warned that Brazilians will have to "coexist" with the disease for the foreseeable future (4)
.
Thanks to effective insecticide measures, dengue had been largely eradicated from much of Latin America between 1950 and the early 1980s. But, as those efforts faded, and with DDT declared off limits, the mosquitoes reappeared. Last year, over a million people in the Americas became infected by dengue, more than half of them in Brazil, and 70% of those in Rio de Janeiro. In Rio itself, the neighborhoods hit the hardest every year have been its hillside slums, the favelas (5)
.
This year, Aedes aegypti, the mosquitoes that transmit dengue in Brazil, became a vast insect horde. They propagated en masse in the stagnant gutters, drains, and puddles left by the record-setting rains of the Brazilian summer of 2008. Nurture was added to nature. Superstitious slum dwellers and the drug lords who run favelas such as the teeming Cidade de Deus (City of God) prevented uniformed sanitary workers from entering their fiefdoms. Sad to say, children under 15 accounted for almost half of the deaths from dengue in Rio (5)
.
THE VIRUS AS PATHOGEN
The epidemiology and pathophysiology of the dengue virus have been well-studied. Dengue virus is a genus of the Flaviviridae family, which consists of more than 68 members, most of which are borne by persistently infected arthropod vectors that go on to infect their vertebrate hosts. The enveloped virion of a flavivirus contains a single-stranded, positive-sense RNA genome of approximately 11 kb, whose replication is primarily cytoplasmic and membrane-associated (6)
. A variety of mosquitoes carry the four serotypes of dengue viruses (D1–D4), which differ only slightly in their capacity to cause dengue fever, dengue hemorrhagic fever (DHF), or dengue shock syndrome. A first infection by dengue virus is usually mild, almost flu-like; but the severe forms such as "breakbone fever" with its triad of fever, rash, and acute muscle pain, usually follows the second exposure to the same or any other serotype. The crueler syndromes that lead to death—dengue hemorrhagic fever and hypovolemic shock—tend to affect younger patients, with mortality rates up to 60% (6)
.
The disaster of dengue hemorrhagic fever is caused in large part by immune complexes in which viral antigens are tagged by our own antibodies (7)
. These in turn provoke receptor-mediated clumping of platelets and white cells in the circulation; when such aggregates get stuck in the blood vessels of lung or kidney, organ damage ensues. The blood vessels are themselves injured by chemical messengers of inflammation (e.g., eicosanoids, kinins, complement-derived anaphylatoxins). Acute respiratory distress syndrome and disseminated intravascular coagulation follow, as activation of endothelial cells and macrophages floods the system with procoagulant factors and inflammatory cytokines. Fibrinolysis, vascular leakage, hemoconcentration, and—alas—exsanguination are terminal events (6
, 8)
. There is no specific treatment other than hydration and/or transfusion; steroids are useless.
MACUMBA AND THE FLYING SYRINGE
Since dengue fever and DHF cannot be adequately treated, only preventive measures can quell an epidemic. Alas, in Rio this year, politics stood in the way of prevention. The doctors’ union accused the local government of criminal negligence in protecting public health. The doctors complained that Cesar Maia, the mayor of Rio, refused to appeal to the federal government for sufficient public health workers. Instead, the mayor trekked to a mountain top in Bahia to plead with a local Macumba deity to rid the country of mosquitoes. Issuing a statement that may sound familiar to North American observers, the president of the doctors union protested that "The threat of an epidemic was already apparent since last year and the city did nothing. The mayor can’t run for re-election, so he left it all to luck and the Lord (9)
." Or as they put it Portugese "Enquanto o digníssimo Prefeito da Cidade do Rio vai fazer macumba na Bahia pra espantar o Aedes aegypti." (The estimable Mayor practiced Macumba in Bahia to exorcise the mosquito.) (10)
.
Macumba—the name is of West-African origin—describes a religion that mixes African fetish worship, Brazilian spiritualism, and Roman Catholicism in various proportions. The original African fetish gods, or Orixás, became equated with their corresponding Christian saints and are now equally honored. From humble beginnings in the slave ships of the eighteenth century, the sacraments of the two main sects of Macumba, the Candomblé and Umbanda, have become quite theatrical. The ceremonies feature ritual blood sacrifice (mainly of crowing cocks), scented candles, burning incense, and buckets of fresh flowers. They are led by mediums who communicate with holy spirits by falling prostate before outdoor altars surmounted by the sign of the Cross (11)
. As dengue decimated the favelas of Brazil this year, cries of the cock and aromas of wax filled the air. What was missing was a whiff of insecticide (10)
.
The Caribbean basin and Central America became centers of a similar brand of syncretic religion, called Santeria. After the Cuban exodus of the early 1960s, Santeria entered the US on the coast of Florida, where its practice has run into difficulties over those crowing cocks (12)
.
Central America and the Caribbean basin have also become a vast reservoir for the dengue virus; indeed, outbreak after virulent outbreak has prompted major US aid. (13)
. Over the last 20 years, serotype circulation in the region has gone from none or single to multiple, and the mosquitoes are moving north. Our porous southern border has permitted dengue to become endemic in southern Texas, and the disease is now moving into California. (14)
. "Mosquitoes are flying syringes," warned Dr. Cortez-Flores of Loma Linda School of Public Health, an expert on the arthropods (15)
. Syringes know no borders.
The notion will be familiar to students of the slave trade and its cruelties. Aedes aegypti, a prime vector of not only of dengue but also of yellow fever, reached South America in slave ships on which the mosquitoes’ eggs survived in water containers while live mosquitoes fed on the helpless Africans and sailors on board. Michael Nathan, a WHO entomologist, noted that "A lot of slaves and a lot of crews died of yellow fever on the way over (16)
."
MACUMBA AND THOROUGHWORT
Sandro Cezar, president of the Rio de Janeiro state health workers’ union, accused Rio’s mayor (Cesar Maia, that fan of Macumba) of turning down an offer of some 3200 federal sanitary aides, because of a political dispute with the federal government. The mayor defended himself to the AP: "That’s a lie," he said, and blamed political agitators "who don’t want to work" for spreading false accusations against him (9)
.
But the fight against dengue gained support from other quarters. The British super-model Naomi Campbell stretched a white "Rio Against Dengue" T-shirt across her poitrine to lead a drive for blood donation (17). Others took their cue from Dr. Dráuzio Varela, a TV practitioner, who gained national attention by suggesting that the simple addition of a spoonful of soup to stagnant waters would instantly kill any insect larvae present: "Better than DDT!" he told viewers (18)
. Offering dilutions of grandeur, a team of healers from the Homeopathic Action Group for Humanitarian Aid (Homeopatia Ação Pelo Semelhante, an NGO), offered their services to 40 children at a State Hospital in Rio. Erroneously, the well meaning homeopaths asserted that "The faster the disease comes on, the faster is the recovery (19)
." One finds that the treatments recommended by homeopaths for dengue fever include Eupatorium perforatum, (thoroughwort) and white briony at almost infinite dilutions (20)
.
These unorthodox measures proved futile. Owing to her medical history, the super-model’s offer of blood was refused and an entymologist of the eminent Oswaldo Cruz Institute went before TV to show that Dr. Varela’s spoonful of soup had absolutely no effect on the viability of Aedes aegptii larvae (18
, 19)
. And as for Homeopatia Ação, a controlled, randomized study had already shown that 1024 dilutions of thoroughwort and other herbs were no more effective than lactose in the treatment of dengue fever. Large names, little herbs, with little efficacy: Aconita, Bryonia, Eupatorium perforatum, Gelsemium, and Rhus toxicodendron (21)
. Those charming names could have decorated the lyrics of Leonard Bernstein’s Candide in which a doctor offers remedies for the ills of the Lisbon earthquake:
Here be powders and pills
For your fevers and chills.
I’ve a cure safe and sure
For whatever your ills.
For a fit of migraine,
Or a pox on the brain
Here’s an herb that will curb any pain! (22)
CANDIDE IN ELDORADO
Voltaire was prompted to write Candide (1759) in response to the great Lisbon earthquake of November 1 1755, a disaster that killed thousands of innocents, including many children. The disaster literally shook the philosopher’s faith in divine providence forever:
After the earthquake, which had destroyed three-fourths of the city of Lisbon, the sages of that country could think of no means more effectual to preserve the kingdom from utter ruin than to entertain the people with an auto-da-fé, it having been decided ...that the burning of a few people alive by a slow fire, and with great ceremony, is an infallible preventive of earthquakes (23)
"Auto-da-fé," I might add, is Portuguese for "act of faith," and to my mind would cover both the burning of heretics by the Inquisitors in Lisbon and the mayor’s appeal to Orixás after the dengue epidemic in Rio. "What a day, What a day, for an Auto-da-fé," they sing in Bernstein’s musical—what a day, what a day to blame someone else. If syringes know no borders, natural disasters know no end of blame. The Mayor blamed outside agitators, the doctors blamed the mayor, journalists blamed the drug lords. Brazilian nationalists blamed Mexicans and Caribbean islanders for permitting mosquitoes to flourish in the Americas (2, 4). Voltaire blamed credulity.
Candide, having witnessed earthquake, mutilations, and that Portuguese auto-da-fé, recalls the pablum fed him by his mentor, Dr. Pangloss, and asks the proper question:
Candide, amazed, terrified, confounded, astonished, all bloody, and trembling from head to foot, said to himself, "If this is the best of all possible worlds, then what are the others? (3)
Voltaire transports Candide to Latin America to try out life in one of those New Worlds and to find his lost love. He encounters unlettered natives, overworked slaves, and colonial rascals; he finds corruption and sloth as rampant in South America as in Europe. And then he’s off to a land that all of us dream about: Eldorado.
ORDEM E PROGRESSO
Today, Brazil may not be Eldorado, but it does contain a society as broadly tolerant, diverse, and multiracial as any on earth. Macumbans worship next to Roman Catholics. Black and white, Indian and Iberian, Candomblé and Umbanda sun themselves and make love on the sands of Ipenema; they also spawn those amazing soccer players. The country fulfills Voltaire’s prophecy that "If a land has only one religion, it tends to despotism; if it has two, they are at each others’ throats. If it has thirty, they live together in peace (23)
."
When slavery in Brazil was abolished in the 1880s by a republic that overthrew its monarch (24)
, the country adopted a motto on its flag that remains there today: "Ordem e Progresso." Order and Progress are no shabby principles to sport on a country’s flag (24)
. The motto is adapted from August Comte, the French physician and positivist, whose Plan de travaux scientifiques nécessaires pour réorganiser la société of 1822 was based on Voltaire’s notion of society based on reason and religious tolerance. Comte’s vision of a just polity added fraternal love as a first principle: L’AMOUR POUR PRINCIPE ET L’ORDRE POUR BASE; LE PROGRES POUR BUT (With Love as principle, Order as foundation, and Progress its aim) (25)
. Comte acknowledged that he was much in debt to Voltaire’s wandering optimist, Candide, who found his Eldorado in a fictional Brazil where:
Candide asked to see the High Court of justice, the Parliament; but was answered that they had none in that country, being utter strangers to lawsuits. He then inquired if they had any prisons; they replied none. But what gave him at once the greatest surprise and pleasure was the Palace of Sciences, where he saw a gallery two thousand feet long, filled with various devices of mathematics and natural science (26)
That gallery came to life a century ago when Brazil founded its Instituto Oswaldo Cruz to put "science at the service of the Brazilian people." Its scientists busy themselves with the newest devices of molecular biology to map the dengue virus and make its diagnosis neat and rapid (27). Finally, as this is written, the federal government of Brazil has over-ridden the mayor and is moving its batallions of health workers into Rio to kill mosquitos and cleanse the favelas.
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