What is informed consent?
I believe that it is a process involving two people: the doctor and the patient. The doctor transmits a message to the patient and ensures that the patient has understood it. Using this information, and with the doctor’s help, the patient is then able to arrive at a decision.

As a researcher, you need the patient’s authorisation before you can include him or her in a study. What rights does the person who signs an informed consent have?
The main one is the right to be informed. He or she must understand the procedure and risks which the treatment or research entails. In addition, participants in trials have the right to end their participation at any time. In the case of treatment, the situation is more complex, as once the treatment has started there may be negative consequences if it is terminated prematurely.

The context in which you work in Africa is very different from the western one. How do you resolve the problem of applying international regulations designed in the west which do not take into account the specific characteristics of other regions of the world?
It can be very difficult. In my country, Mozambique, and across the whole of Africa, it is often difficult to apply them because of a lack of the appropriate tools. Our health networks do not have as many resources as those of other countries. In addition to these material barriers, there are also cultural barriers which complicate the doctor–patient relationship. In African culture, asking people to sign an informed consent form makes people very suspicious because of the negative connotations of signing official forms. There are also linguistic barriers. Some languages are spoken but not written, and this means that medical professionals need to find other ways of communicating with patients.

To what extent is there a clash between cultural traditions and medical requirements?
In my country, everything depends on how much trust the health professional inspires in the patient. Anyone who seeks medical assistance places all their hopes in the doctor because they are often not in a position to understand what they are being told. Our job is to put ourselves in their shoes and try to understand their situation, even if we don’t have enough time to spend with each patient. Another issue to take into consideration is the central role played by the family when it comes to taking decisions. This is why we often advise patients to take information home so that their family members can help them to understand it and to reach a decision.

You have undertaken research in Spain and Mozambique. What differences have you encountered?
Spain has better structures to support research. However, in Africa it can sometimes be easier to start a project because the situation in our continent means that research can always be justified. It is difficult to set limits when the problems are so serious. It would be best if there were two or three medical committees to consider these issues, but in many countries like Mozambique there is only one.

In Mozambique you have directed the Health Research Centre of the Manhiça region, where you have conducted a number of studies into malaria, AIDS and nutrition. How did the idea of the project arise?
The project brought together the governments of Spain and Mozambique, the Hospital Clínic in Barcelona and various organisations in my own country. It all arose from the need for a high-level centre based in a rural area which could deliver health improvements by providing integrated healthcare, training and research services. The first thing we did was to define our area of operation and take a population census, which is then updated every six months. This initiative has really helped us to find individuals for inclusion in our studies. Once the census had been completed, we initiated research projects on some of the major diseases affecting the country, such as malaria or HIV.

What is the usual procedure for a research project in Manhiça?
When proposing research, we always consider the priorities for the country as a whole. This is easier in Mozambique because, unfortunately, the problems are all too easy to identify. Then the project is presented to the Government. If the protocol involves various countries, the ethics committee of each has to evaluate and approve it. The country where the study is to be carried out is the last one to intervene in the approval process. At the beginning, we only conducted descriptive research, but we have now extended this to look at issues such as drug treatments, vaccines, mosquito nets etc.

How is the centre structured?
The Manhiça centre now has 250 staff, but only eight of these are doctors. In just a few years we have expanded our radius of operations, and have doubled the number of people we treat, to reach the current figure of 70,000. Because one of our key aims is to create a sustainable centre, it is vital that any doctors working with us help to train Mozambican staff.

And finally, how do people view you and what role do doctors play in African society?
In Africa people used just to hand their bodies over to the doctor, without asking any questions, leaving everything up to him. Patients have gradually become more involved in health processes, although sometimes they have difficulty understanding this. Although doctors have always been respected throughout Africa, unfortunately the conditions we work in are far from ideal and this means we are unable to spend as much time on each patient as we would like. In Mozambique there is one doctor for every 150,000 inhabitants, a figure which certainly makes our job far more difficult and which means that any patient who sees a doctor feels privileged, because they will often have waited for up to six months for their appointment. This also means that doctors are very conscious, when seeing patients, that it is a very special moment for the patient, even if the doctor may be able to spend no more than five minutes with each individual because so many others are waiting. It’s a pity; you’d like to be able to do more but the resources just don’t exist.