The Anti-Vacation

The blue line represents the 2012 rate of malaria in Androy compared to 2011, in red, and 2010, in green.

Alyssa reviews patient registers with the midwife in Andalatanosy.

The midwife and her husband, the Chef CSB, invited us for lunch.

A cluster of houses in Bekopiky Sud.

Laura and Hermann conduct a verbal autopsy with Bekopiky Sud villagers.

Hermann delivers new medical stocks of medicine to a CSB outside Bekily.

Many of the rural Antandroy still wield traditional weapons, like hatchets, javelins, and zebu-hide slings.

Alyssa enters data during a power failure in Bekily.

Hermann and Perlinot examine the plant samples from the ombiasa.

A street view of the hospital in Bekily.

A Verreaux's sifaka peers down from a neem tree at Berenty Reserve.

Written July 9, 2012

Manambaro

To make better sense of the geography in this post, it might help to look up south-central Madagascar on Google Maps.

For more photos from the mission, go to www.oxanddolphin.blogspot.com

    I wanted a change from Manambaro.  I got it.  Two weeks of nonstop work researching a deadly pathogen in the harshest landscapes this island has to offer.  A thoroughly satisfying experience.

    First, a bit of background on this mission: in late January the Malagasy Ministry of Health (MOH) began getting reports of many more malaria cases than normal around Bekily.  The malady spread southward to Andalatanosy, Tsiombe, and Ambovombe.  To have any more than a scattering of malaria in the Androy region was alarming-- mosquitoes tend not to flourish in the desert.  Yet now it appeared to be enveloped in a full-scale malaria epidemic.

    In cases like this, the American Centers for Disease Control and Prevention (CDC) sends a team to verify whether the on-the-ground data really does indicate an epidemic.  If so, the team gathers further information to help other US government agencies, like USAID and Peace Corps, prepare a counterattack.

    The team in this case were Doctors Alyssa and Laura.  Laura had just finished a fellowship with EIS, the Epidemiological Information Service, while Alyssa was a CDC veteran.  They had asked for a Peace Corps assistant in order to have a translator and extra set of hands.  Sammy, our driver, is a Tana man, and so my Antanosy would be closer to the Antandroy dialect than his Official.

    We started west from Fort Dauphin on the 22nd, stopping to pick up some fruit in Manambaro.  We made it through Amboasary unmolested and were in Ambovombe by mid-afternoon.  We rendezvoused at the hospital with the three Gasy doctors from Institut Pasteur who would be helping us, Hermann, Perliont, and Marcel.

    After collecting all the data we could in Ambovombe, we set off immediately the next day for Antanimora, going further away from the coast and into the parched savanna.  In the early mornings the desert around Ambovombe creates fog in the low places; when the sun hits the mist it looks like a huge, shimmering lake.

    Our work in Antanimora dealt with the cases of malaria in Vohitsova, a smaller village outside of town.  Rocky ground, bristly grass, and cactus everywhere.  At night we slept on the floor of the Antanimora CSB.  I learned quickly that our schedule was going to be like that on board the USS Iwo Jima: rise at five, work all day, and go to sleep at eleven.  Eight hours of sleep?  Whatta you, a convalescent?  You’ll take six hours and be thankful for it.

    On the other hand, I think there was more food on the Iwo Jima.  Yummy MREs, 3000 calories all to myself...  Even if our schedule had allowed us time for a sit-down lunch, we were out in the bush.  The one time we relied on a local to make us rice we ended up waiting two sweaty and nerve-fraying hours.

    From Antanimora we continued north to Andalatanosy, the kind of town that must have once existed in the American West.  Ramshackle buildings on either side of a dusty street running out to either horizon.  Gigantic trucks trundled past, taking the place of wagon trains.

    We arrived in the middle of the Vingt-Six ceremonies.  June 26 is Madagascar’s Independence Day, the biggest holiday of the year. We tracked down the CSB midwife at the mayor’s house, where the various chefs fokontany (headmen of smaller villages) were gathered.  The mayor received us warmly.

    The men turned to walk to the town square, hurrying us along, too.  We passed through a thick crowd of schoolchildren and into the speakers’ pavilion, draped with red, white, and green.  A man was already in the middle of a speech, but he finished quickly to allow the mayor to make his.  The mayor hardly mentioned us, the “foreign visitors.” (“vahiny avy andafy”)  Several officials came after the mayor, each taking the opportunity to remark on how auspicious it was that foreigners had shown up for the Vingt-Six celebration.

    Finally, a health official took the podium and made a speech.

    “We all know that fever is a problem in this town.  But when someone falls sick in the family, too many people do the wrong thing!  They go to the church to pray, or they go to the witch doctor!  Neither of these things will help!  You need doctors, not witch doctors!”

    I was impressed, specifically about the mention of the church.  The Gasy are usually a lot more delicate about Christianity.  I guess this guy was just fed up with so few people seeking help at the clinics.

    He motioned for us to stand up as he introduced us: “Éric,” “Law-ra,” and “Alish.”

    After the ceremony, Alyssa and I did some house-to-house work in the village of Bekopiky Sud, seeing how many households had mosquito nets, and what shape these nets were in.  Most villagers don’t sew the holes in their nets, either because they don’t know they should or they’re too poor to afford a needle and thread.  Laura and Hermann did a verbal autopsy on a child who had died weeks before, asking a series of detailed questions to see if the cause had been from malaria.

    From Andalatanosy we continued on to Bekily, which presented something of an enigma to me.  It is literally in the middle of the desert, yet it’s noticeably larger than the other desert towns.  There’s a river, but it’s too shallow for boat traffic.  It’s not on RN13, the north-south road.  I don’t know how old the town is, but maybe it was once so far away from anything else that it served as a refuge in war.

Médecins Sans Frontières (Doctors Without Borders) chose Bekily for their Madagascar headquarters, specifically because it’s so isolated and in need of help.  The French doctors founded a hospital and brought in Gasy counterparts.  

    When we first arrived, the MSF team invited us to their living compound for dinner.  The doctors were Delphine, Valérie, Kévin, Caroline, Cecile, Élizabeth, and Milton.  Milton was the sole Canadian.  He was whip-thin from a recent bout of schistosomiasis.  From him, Laura realized something.  If malaria was rising in the region, why not other other water-borne parasites like schisto or Leptospirosis?  The latter can even cause symptoms easily mistaken for malaria.

    The dinner was a savory fish stew served over potatoes.  The French have many flaws, but their cooking is ever superb.

    They even let us use their guest house, more comfortable by far than any other place we’d stayed.  It was much like a Scandinavian summer home, with a high roof and lofts for sleeping.  No decorations or chairs, but there were soft beds and running water.  In the mornings we met with Élizabeth for strong French coffee and tartines.

    Other doctors joined our team: Solo and Entsoa were also working for CDC, and Andry was with the Ministry of Health.  We covered a fair number of villages around Bekily: Tsikolaky, Anjata, Antsakoamara, and others.  More verbal autopsies and house-to-house net inspections.  But these villages held a secret.

    Especially in Anjata, we found that traditional medicine holds sway over modern methods.  When stricken with malaria, villagers almost always go to the witch-doctor, the ombiasa, before they travel to the nearest CSB.  On one level, it makes sense; to get to the CSB takes hours by plodding cow cart over miserable, rutted dirt tracks.  Every village has an ombiasa, or at least someone who claims to be able to heal with herbs.

    The health official in Andalatanosy talked about the ombiasa in his speech.  The difference here was that the ombiasa around Bekily take a more sinister approach than merely administering cures.  The ombiasa tell the villagers that Western medicine means death: “If you take pills, you’ll die!”  “If you get a shot, you’ll die!”

    And the villagers, never having set foot inside a classroom, believe them.  Magic is a part of life in these settlements.  In Anjata we found women wearing charms around their necks, and smearing their children’s heads with clay.  One house had an amulet of carved sticks above the door, while other houses were painted with a ring of gray mud.  All these rituals are to fend off malevolent spirits.

    Since they know that outsiders frown on what they do, no ombiasa would reveal himself to a white person.  Luckily, while Alyssa and I were busy elsewhere, Perlinot was able to persuade one to point out which plants he uses to treat malaria.  He produced two bunches of herbs and a length of root.  When crushed and boiled, the plants give a bright yellow potion.   In the wrong dose this mixture is fatally toxic.  We took samples of the plants for analysis, to see if they really do counteract malaria.

    On the last day in Bekily I came down with diarrhea and chills.  Alyssa and Laura, being doctors, insisted that I rest and hydrate.  They wouldn’t hear of me getting up to help them.  Thankfully I mostly recovered by evening.

    The next day we pulled into Ambovombe.  While Alyssa and Laura collected fresh statistics, I went to find some souvenirs.  

    Heading back to Fort Dauphin Sammy asked us, “You want to see some lemurs?”

    He turned onto the dirt road that led to the Réserve Privée de Berenty, a very expensive wildlife park and resort.  This is the kind of place that’s designed to isolate foreign tourists from the fact that they’re in a developing country: hot baths, graded walking trails, gourmet food, and lots of tame lemurs.  A van runs between the park and the Hotel Kaleta in Fort Dauphin.

    At the gate was a scowling guard carrying a big black machete.  I’d wager the management told him to carry that machete specifically to scare the tourists:

    “Ohmigod, you guys, is he gonna, like, chop our hands off or something?  I’m, like, freaking out, you guys, this is just like Blood Diamond.”

    ‘Swhat I’d do if I ran a resort in Africa.

    Sammy knew that while the van from Fort Dauphin costs €200, admission for day visitors is free.  We stopped there for only half an hour, but that was all we needed to see a troop of Verreaux’s sifakas in the treetops.

    We crossed the mountains, the barrier between desert and greenery.  After miles and miles of savanna the valley looked incredibly lush and inviting.  

    We returned to Fort Dauphin with a few hours to spare before Alyssa and Laura’s flight back to Tana.  We set up in the lobby of the Kaleta, and made use of the time to enter more data, preparing the presentation that would go before USAID.

    Around three o’clock, after stepping outside for fresh air, Alyssa came back in grinning.

    “It’s breathtakingly beautiful outside.”

    Laura went to see the view over the bay in the golden afternoon light.  Sapphire water, snowy beaches, and the majestic mountains as a backdrop.

    “Yeah, you’re never going to be able to leave a place like this,” she told me.

    “Probably not,” I agreed.