Health

DISCLAIMER: I am not a heath sector volunteer much less a health expert in any position to comment authoritatively on any of Madagascar’s many medical issues. Actual responses to illnesses among Malagasy vary based on location, income level, and culture. The following post was compiled only on the observations made by myself, other volunteers, and Malagasy friends. No empirical studies were reviewed, no data was collected. What I’m trying to say is I am full of it per usual.

Knock on wood it has been 22 months now and I have managed to avoid becoming seriously ill in the Peace Corps. I have never been forced through a taxi brousse ride while vomiting or incontinent. The Peace Corps has not had to fly a helicopter down to my site to rescue me from the brink of death. I have not been evacuated to South Africa for observation and treatment. I do not have malaria. My most serious medical predicament to date involved accidentally smacking a wasp nest with a broom and the subsequent allergic swelling. Much of this bon sante is due to the wonderful and attentive medical staff that is on call 24/7 to patiently listen to volunteers as they describe their problems, real and imagined; usually something about the frequency, consistency, and appearance of their bowel movements.
In training, we are issued a black medical kit that is supposed to contain all the medicines and materials we could need to treat ourselves at site. It also came with two paper bags stuffed with materials that couldn’t fit in the black box as well as a hefty instruction manual. Most ailments can be dealt with from the contents of this kit or through the judicious application of Tylenol and/or patiently allowing symptoms to work themselves out. I have been put on antibiotics only once. I still take my malaria prophylaxis so thus far I have found Madagascar to be a medically uneventful place.
The responses to the medical challenges of Madagascar I have observed by groups of non-Peace Corps vahaza (tourists) have been far less reasoned. Many arrive on the island flouting their rejection of all three prophylaxis options citing concerns over mefloquine’s psychoactive properties, malarone’s high price, and the impact of an antibiotic like doxycyline might have on their precious digestional bacteria. This attitude persists until someone in the group comes down with a case of runny stool or a cold. Then all the stops come off and ridiculousness ensues. Not only is someone sick, they are sick IN MADAGASCAR which obviously is 1000x worse than any normal ailment and thus justifies a proportional response that defies all common sense. I have, on more than one occasion, seen colds (usually mild and of the viral persuasion) treated, without medical consultation, with cyprophlaxicin, a powerful antibiotic that acts like Drano for the GI tract. Intestinal bacteria are written off as collateral damage Everyone attending to the stricken tourist raids their zip-locked medical bags to see what sorts of prescription-only pills their doctor sent them in case of extreme emergency. Tamaflu, Coratem, and last defense antibiotics, everything is on the table. When Alison was down with a case of dysentery, one tourist wisely prescribed her Ammodium and some other pill whose properties he was not familiar with, “but it cost $300 so it should work”. Fortunately she refused as Ammodium coupled with dysentery has been known to kill patients as pressure from backed up wastes can cause the gut to burst.
It may seem counterintuitive but the rainforest, I have found, tends to be healthier than other areas of Madagascar because the water running off the mountains is clear, fresh, and hasn’t been despoiled by animal/human urine/feces/wastes. Additionally, the healthy population of feral frogs, lizards, chameleons and bats keeps the mosquito population at a minimum. Everything downriver to the east is another matter altogether. Rural Malagasy seem to have a special penchant for reliving themselves directly into community water sources, a practice I have been forced to witness/deal with the consequences of at least three times this week. And when it comes to water and disease everything revolves around feces. Our doctors succinctly informed us in training that any intestinal ailment we contract is as a result of germs originating from the intestine of someone or something else. Against this volunteers are armed with filters and bleach drops, but the general populace is left to their own devices. Madagascar has a serious lack of toilets, a recent study concluded that lack of toilets/outhouses cost the country an estimated 17.6 million dollars a year in sick workers and lost time spent wandering around looking for someplace private behind the bushes. How one would collect data for such a study is somewhat suspect, but its conclusions are not shocking. Indeed the entire commune of Lopary contains only three outhouses, one notoriously flimsy one is reserved for the resident Peace Corps Volunteer.
The proceeding should not be misconstrued to conclude that there are not serious and dangerous illnesses in Madagascar. There are many including, but not limited to rabies, typhoid, malaria, yellow fever, dengue fever, shistosamyasis, dysentery, and the plague. Syphilis is rumored to run as high as 30 or 40% in some areas. However, these diseases are transmitted in ways that most vahaza and volunteers can avoid by being safe with their water, food, prophylaxis, and choice of intimate partner. Many Malagasy people don’t have that luxury or don’t know what choices are available to protect themselves. Additionally many people live far from doctors and medical dispensaries. In Ranomafana, for example, there is one doctor who works out of a small facility in town that services the entire commune of 25,000 people. Most of these people live hours hike over steep mountains and dense foliage away and are not likely to make the trip if they are feeling under the weather. Often people wait until things get critical before attempting to move a sick person when it is often too late. In many villages there are ‘Ombiasa’ or medicine men called upon to attend to the sick. Here medical blends with spiritual as many Ombiasa require possession by a spirit to conduct their healings. One Ombiasa near Ranomafana can purportedly heal broken bones in as little as three days with the discerning application of zebu fat and his own saliva. Most prescribe some combination of native plants mixed into something approximating tea. Unfortunately the spirits possessing these earthly vessels keep poor patient records so their actual effectiveness is somewhat of a mystery.
Those living near the village and the road tend to report to doctors somewhat regularly. Without fail, doctors tend to prescribe the same solution for every symptom: bludgeoning the disease to death with low-grade antibiotics. Amoxicillin, tetracycline and lots of other things with the suffix “lin” seem to be indiscriminately prescribed for whatever ails you. Some, including my neighbors, swear by the big yellow and brown amoxicillin pills that they bring back biweekly whenever some family member has a cold or headache. If baby Kanto happens to be showing symptoms, antibiotics are applied intravenously. I can’t imagine there is a single bacterium left on the island that is not immune to amoxicillin. The same drugs are dolled out for livestock but without any instructions on dosage or how to get your sick chicken to ingest a human sized dose of tetracycline. Other drugs are around. I happen to know that the lady down the street in the obnoxiously green cement house sells a host of exciting generics that in any country with laws would be prescription only. These are either too expensive and/or unfamiliar to most villagers. Someone more entrepreneurial than myself could make a killing distributing sugar capsules under the label “Super Amoxycilin-cylcin.”
While we are on the topic of heath, I would like to add an appendix (pun) on Malagasy dentistry. The dentist of choice for the Peace Corps office is the lyrically agreeable ‘Adventist Dentist’ on the East end of Antananarivo. Volunteers are entitled to one cleaning annually which is usually conducted in less than ten minutes with varying degrees of professionalism by two attendants who have been known to place as many as four hands in the oral cavity at any one time, well above the carrying capacity of most mouths. More serious dental trauma, usually a result of sorting rocks out of rice with one’s molars, can bring about memorable experiences with root canals or fillings requiring multiple commutes to the capital.
Unfortunately for most Malagsy, rice and cassava farming does not come with dental and the consequences are immediately obvious in towns and villages. The absence of any corrective orthodontics leaves some villagers with shark-like arrangements of teeth protruding from gums at all positions and angles. When three or more teeth attempt to occupy the same space, the results are never pretty. The bane of Malagsy smiles, however, is not the lack of retainers of braces it is sugarcane a.k.a. fary. When it’s not being grown plantation style to make granulated sugar, fary us useful for exactly two things: munching on raw and brewing moonshine. While the latter is widely distributed in proofs north of 90 with easily foreseeable consequences for the liver, masticating on the tough fibers does for teeth what an industrial sander and saltwater can do for the exterior of a sports car. Despite this fary remains extremely popular because it is sweet, cheap, and is a wonderful way to get rambunctious children to shut up and mind themselves for a while. Gums are not exempt from the oral devastation either. Many Malagasy are addicted to 50 ariary bags of snuff that they cram under their front lip while they go about daily tasks. The gums proceed to rot like month old wonderbread, taking on a piebald pattern not dissimilar to spoiled meat. What few skeletal teeth might be left at this point stick out of the receded gums like the stained monoliths of some ruined Greek temple. Fortunately most Malagasy cooks adhere strongly to the boil-everything-until-it’s-a-mushy-paste school of culinary arts thus teeth are precluded as a necessary prerequisite to normal digestion.

Nosy Be

Nosy Be is a play land for white people. Much like a prison or sewer plant is build far from an American metropolis to avoid making a spectacle out of something large and socially embarrassing, Nosy Be’s geographic isolation from the mainland seems designed to insulate the island from the typical life on the mainland. It, however, doesn’t house dangerous criminals or emit noxious fumes; it houses foreign people, their money, and the facilities to suit their extravagant tastes.
Getting to Nosy Be, however, is a less than glamorous affair. Unless you have booked yourself a direct flight from Milan or Paris, the only way to the island is through the port of Ankify. This noisy harbor is perched on a small rocky outcropping and is infested with seasoned transportation extortionists, slumping shacks, and fortified groups of white folk trying earnestly to appear calm. My theory holds that Ankify’s atmosphere is intentionally surly its tattered tarmac deliberately caked in sticky mud to entice stranded tourists to lay down unspeakable sums of money to be taken anywhere else by the fastest possible means. The only economical means of transport back to Ambanja consists of a small fleet of dilapidated station wagons with decimated facades that seem to be begging to be taken out on the ferry for aquatic euthanasia.
The seaborne transportation is hardly more encouraging. The larger ferries look like botched efforts to transform large objects not known for buoyancy into amphibious craft. One ferry almost certainly served some time as an industrial shipping container and another appeared to be floating balcony or patio off a demolished high rise apartment building. These car-bearing rust buckets don’t really ply the water as much as bulldoze it with their distinctly un-nautical flat bows and rectangular disposition and usually require three hours to make the voyage to Nosy Be. We opted to shell out an additional $2.50 for one of the faster passenger-only ‘speed’ boats that, already loaded with Malagasy passengers, maintained a not quite comfortable clearance above the waterline. As we smashed ourselves on the plastic bench, our skipper tossed us one life jacket to split between the four of us as we pushed off.
One arrives in Nosy Be via Hell-Ville, a town named for some obscure French naval officer and not for its likeness to the abode of the damned. It is the largest town on Nosy Be sporting breezy boulevards and colonial architecture akin to Diego Suarez. Hell-Ville doesn’t have any nearby beaches or resorts; instead it thrives providing the services for the resort towns scattered about the island’s coast. We did not dally here long and after disembarking at the port made for Ambatoloka by taxi.
Ambatoloka is Nosy Be’s largest beach resort complex. It is a two kilometer coral beach consumed entirely by hotels, guest houses, bars, etc. All of this excitement was, of course, well beyond our volunteer salaries so we booked windowless cement rooms sans hot water just inland from the beach. For the next three days we plied Nosy Be’s various beaches by taxi and spent entire days lounging about sipping beer and staring out on at Nosy Be’s beautiful blue waters while ladies with painted yellow faces walked by selling lambas, fruits, and massages. The most spectacular beach on Nosy Be is Andilana. Located on the Northern tip of the island on a large cove, it is only sparsely populated with resorts and contains few tourists. The white powdered sand slopes slowly out to sea so as the tide receded in the afternoon, we could lie in surf only a few inches deep and let the cool waves crash over sunburned shoulders.
Although Nosy Be exists in a world separate from the mainland, there are places on Nosy Be that are themselves bubbles of such unfathomable wealth and privilege. Venta Club, a swanky Italian resort on the north side of Andilana is one such place. The cost of just wandering onto the beach is a hefty 30 €. Walk-in reservations are not welcome. Clients, flown in directly from Europe, enjoy all-inclusive rights to all food, excursions, services and amenities. Occasionally a pack of Italians would wander off their reserve down the beach under escort from well-dressed Malagasy attendants whilst the PCVs lying in the surf made rough appraisals in the upper hundreds of dollars of their in-vogue swimwear and ocular UV protectors. On another occasion, slightly lost on the beach in Ambatoloka and searching for a short-cut, we wandered in some resplendent resort that made us dirty broke beach bums feel wholly out of place and we slunk out of the vaulted reception area without making eye-contact.
Just because Nosy Be is isolated and vahaza infested doesn’t mean it doesn’t have a vibrant Malagasy atmosphere or an exciting nightlife. Some of the nicest Malagasy I have met were on Nosy Be selling street food or just striking up a conversation at a local bar. However, good portions of the Malagasy frequenting the vahaza hangouts are prostitutes. Prostitution is huge on Nosy Be, especially in Ambatoloka to the point were many hotels now refuse services to single men. Thankfully, once you have established the fact that you are not interested in their services, most Malagasy women of the trade are surprisingly courteous and have the uncanny ability to dance the night away and have an apparent good time even when all potential clients have disappeared. The clubs of Nosy Be are also a great place to enjoy live Malagasy music as nationally renown singers often come to the area to vacation and put on shows. We were lucky enough to run into notorious Malagasy heartthrob Fandrama while visiting Hell-Ville. Katie even managed to come away with his phone number.
My time on Nosy Be was certainly thrilling, and I was not even able to see most of the island’s major draws. These include world famous snorkeling and diving as well as exploring some of the small outlying islands. Three days, however, is just enough for this PCV. There is such thing as too much of a good thing and with 29 hours of public Malagasy transportation awaiting me on the mainland, my reintroduction to real life was promising to be poignant.

Maromandia

Given Ranomafana’s winter reputation for miserable weather, I collected a few of my vacation days and decided to ditch town and head up to Maromandia to visit my friend Katie. Much like Alison, Katie is a member of the Niger stage, an excellent travel companion and not my girlfriend. Her site is located in the far northwest corner of the island. The area near Katie’s site is hot and dry all year round, consisting mostly of arid shrub land leading out to the Mozambique Channel. She lives nearby Sahamalaza National Park, a newly protected area established in 2007. The park was created for a remote patch of forest that is home to the Blue-eyed Lemur (the only other primate besides humans with blue eyes) and continues to include massive swathes of thick mangrove forest, and a collection of coastal islands wallowing in some of the colorful coral reefs in Madagascar. The issue is there that all of this wonderful biodiversity and wildlife is about as accessible to tourists as Mars or other celestial bodies. Hiking out to desiccated reforestation site on top of a hill, Katie pointed out a mangrove island in the distance where rare Fish Eagles amass like dirty dishes after thanksgiving to nest. On the opposing side of the hill lay a deep swerving valley. The valley floor was blanketed in a concealing layer of trees and screwpalms trailing off into the distance where an escarpment jutted out of the hills and sealed the ravine’s tip. Katie reported that there was a waterfall at the edge of the cliff, but the valley’s steep sides prevented anyone from venturing into it.
Upon hearing this I immediately set about finding a way down, and lo, a skinny path appeared and ten minutes later both of us were picking off burs from our shorts and soothing our scratched legs in the bubbling stream that ran across the valley floor. Setting out East we sloshed through the muddy undergrowth until we emerged on a clearing. The spiny pandanus forest ended abruptly on a large pool of water surrounded on three sides by steep cliffs. Over the east side of the cliffs a heavy stream of water split three ways and plunged about forty feet, crashing loudly on a pile of boulders and spilling into the pond. The damp shaded backside of the cliff was studded with mosses and small purple orchids pushing their delicate flowers out earnestly towards the sunlight. A more beautiful and swimming hole could not have been imagined. For twenty minutes we sat silently on a rock in the dappled sunlight with our feet in the water munching on melted trail mix wondering how on earth we get paid to live like this.
With my penchant for hiking and exploring satisfied, we spent the remaining few days in and around Maromandia, meeting with local counterparts and stuffing ourselves on the North’s delicious foods. On market day Katie bought crabs and her jolly counterpart came over and prepared them with tomatoes, onions and something else that made them taste magical. Another spectacular plate was Akoho voinyo or chicken cooked in coconut sauce and served with a spicy lemon salsa sauce. Although vegetables are almost non-existent and almost all food disappears from the markets during the hot hunger season, I would still take the northern diet over what passes for food in the hotely’s of my region.
Another thing about Maromandia, everyone likes to be naked. Whether you are down at the river for a bath, in the stream doing laundry or just out for a swim, why not disrobe entirely with all your neighbors and do it naked? Maromandia’s nudity complex is compounded by its one and only bridge and primary thoroughfare which provides an excellent vista over the town’s riverside bathing facilities. No one sees fit to make any attempt to cover themselves, and some even shout and greet their friends on the bridge. This behavior may be a result of the northwest’s sweltering temperatures; more relaxed unencumbered culture, or highly developed sense of community. But flaunting our over zealous modesty, Katie and I still did our utmost to avoid catching any bare buttocks in our pictures of the flaming orange sunsets over the river.
I have already published a scathing review of Madagascar’s public transportation system in a previous post, and our drive into Ambanja that morning did not depart from those norms, except that I really enjoyed it. Maromandia has a dumpy brown van that ferries Maromandia’s masses to the regional capital in the morning and faithfully returns before dinner. Affectionately referred to as the “chocolate brousse” by area PCVs, it is driven by an unkempt portly man in a striped shirt. Arriving late, the three PCVs were smashed into the front seat, an arrangement preferable to the muddled mountain of humanity which piled chaotically five and six to a bench in the rear compartment. Katie’s position sitting nearly on top of the driver obliged her to hold down the break pedal with her left foot when the driver stopped and concerned himself with forcing in additional passengers. The Chocolate Brousse has gained an unparralled reputation among the townspeople living along that stretch of the RN6 for his unorthodox way of of the announcing his presence. The van’s abused horn has been beaten so thoroughly that only a feeble electronic fart serves to alert to country folk to his impending arrival. Spotting any pedestrian he would pound the horn, take his hands off the wheel, lean out the window, and do an animated version of jazz-hands into the air bellowing “ARABEEE!” [this is a tribal greeting meaning congratulations] to his adoring public. Children run to the road to greet him, men and women put down their chores and return the quirky jazz-hands wave. Stopping to take on more bodies, our driver greets everyone more completely. “Arabe on your rice harvest!” “Arabe on your new t-shirt!” “Arabe on your house with a small door!” Self-confident women with their distinctive Sakalava quarter-bun hair styles and painted faces mill about and the arrival of the chocolate brousse becomes a community event. Everyone smiles, Everyone laughs, the drivers fat hands thump the horn a few more times and the overloaded chocolate brousse coughs and putters up the hill to the next hamlet.
As we approached Ambanja, we stopped briefly in Andampy. Andampy is the North’s newest sapphire boom town and is a remarkable testament to the destructive power of disorganized humanity. The discovery is only three months old, so recent in fact that the rice stalks surrounding the pits still contain streaks of living green. An entire slum has sprawled out from the main road towards the pits. Nearby towns have been emptied of people and produce as more energy and resources go to the mines and away from the rice fields. In typical form, a boom of any precious resource in the 3rd world has proved to be an environmental bust. For days valley floors are ripped apart by hand and the cut earth bleeds into the nearby streams and rivers. The chocolate brousse had stopped near a temporary used clothing stand to drop off another hopeful settler who unloaded a bunch of building materials and set off to make his fortune in the dirt.
Ambanja is an unremarkable Malagasy regional city save its towering triangular bridge and streets lined with towering shade trees. Unlike my regional capital of Fianarantsoa, Ambanja is not blessed with a Peace Corps transit house so PCVs are on their own to find accommodations. In Ambanja, however, a fat old woman with a saintly amount of patience and a spare foam mattress shaped like a comma allows transiting PCVs to overnight in her house. Local PCVs revere “Mama Peace Corps” with a peculiar blend of gratitude and trepidation as quick stops at her place to drop off luggage or catch a nap are liable to digress into long superfluous conversations about local news, family gossip, and the weather. Given that I can only understand pieces of her flowy Sakalava dialect, I snuck in late and left bright and early in a taxi to the port for Nosy Be.

And since this post has already surpassed normal length, I’ll save Nosy Be for another post.