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.