James Penney / Year 4 Medical Student / Manchester
Last year, medical students James Penney, Hannah Russell and Anthony Howe and FY1 Steve Spencer spent seven weeks in a remote region of Madagascar screening school-children for schistosomiasis. They planned MADEX from scratch – coming up with the research aim, finding collaborators, convincing the Ministry of Health (MoH) Madagascar, and finally fundraising in order to pull the whole thing off. We asked them to tell us more about how they ran a large fully-funded expedition while still studying as medical students. Inspiring effort.
Why schistosomiasis? Why Madagascar?
Steve’s mantra for expeditions is that you can start with either 1) a place, or 2) an aim. Once these two are matched up, you have the idea for an expedition. He had previously studied schistosomiasis, a parasitic infection carried in freshwater snails. It is second only to malaria for parasitic diseases worldwide in terms of socio-economic impact. It’s a huge problem in much of Africa, where it has a high associated morbidity, particularly for children. It is easily treatable by a single dose of Praziquantal, however, many African countries, such as Madagascar, have poor infrastructure and inaccessible rural areas. This means many regions aren’t screened for the disease, and many more people aren’t treated. The most recent prevalence study in Madagascar was in 1987 where over 50% of people were found to be infected.
We’d all always wanted to visit Madagascar. It conjures images of biodiversity and intrigue as much as any country; the idea of going to there to do research was incredibly appealing, and so the idea for an expedition was born.
Planning a Student-led Expedition
The seed of an idea took over two years to turn to fruit. The first step was contacting MoH Madagascar to ask if there was any chance of a team of medical students coming out to do some research on schistosomiasis.
After a few months an email came back affirmatively – as simple as that! This set the wheels in motion. From here, we spent long hours researching the natural history of the disease, reading papers and guidelines, and emailing all the experts we could to find out more about the fundamentals of schistosomiasis research. Field diagnosis of schistosomiasis involves examining either urine or stool samples (depending on the species of schistosome) under the microscope to look for parasite eggs.
From reading and expert advice, our aim had emerged: to perform a prevalence study of schistosomiasis in a region of Madagascar, by screening school-aged children. Also to carry out education programmes in schools to raise awareness of the problem of schistosomiasis and how to avoid it, and to interview local health authorities to investigate the disease burden of the area.
We put together a proposal, and were able to negotiate with the medical school to allow us to use our ‘project option’ (an 11 week research block in the fourth year of medicine, usually an audit carried out locally) to go to Madagascar.
We had the beginnings of a plan but had many more questions; where to go? Which species of schistosome to investigate? Did we need permits, and if so, from who? How would we contact the schools? Most importantly, was this actually going to happen, or were we going to have to do an audit in Manchester instead?
Collaboration with Durrell
Whilst at the Royal Geographical Society ‘Explore’ Conference, we met Dr Peter Long, a Zoology Fellow at Oxford who had been on various expeditions to, amongst other places, Madagascar. Peter worked with Durrell Wildlife Conservation, the longest-running conservation organisation in Madagascar, and thought that there was a chance of collaboration. After a few meetings with Peter and his Malagasy PhD student, Hery Andrianandrasana who oversees Durrell’s conservation in Madagascar, a plan started to emerge.
Durrell work with communities to protect ecosystems and environments. Cooperation with local people is crucial for this and is facilitated by improving community health. Durrell knew that schistosomiasis was a problem but had no idea of the scale of it, so they were keen for us to work in their projects and investigate the health burden. We could barely believe our luck – they have fantastic community links.
The work began in earnest. An exhaustive proposal had to be written and translated into French. We applied to a long list of funding bodies for support. A risk assessment had to be completed, detailing the risk of everything from gastroenteritis (9/10 likelihood, 3/10 gravity), to being raided by bandits (4/10 likelihood, 9/10 gravity) and ethical approval sought. We made contact with the University of Antananarivo, who were keen for some of their medical students to accompany us in the field. The validity of our methods and our familiarity with them was also crucial, so we were constantly emailing various experts (Dr Shona Wilson in Cambridge, Professor Russell Stothard at the Liverpool School of Tropical Medicine, Professor Andrew Macdonald in Manchester Immunology Department) for advice and to organise training in microscopy techniques.
This was hard work. For the eight months before departure we were having long coffee-saturated weekly meetings, and firing off emails left right and centre to keep everything moving, but it was also very exciting. The occasional mention of lemurs and vanilla rum helped keep the dream alive.
The Final Pieces of the Puzzle
It was great seeing all these details coming together, but the whole project rested on funding and permits. After a few disappointing rejections we didn’t allow ourselves to assume anything. In April we had confirmation of funding secured. From a combination of The British Medical and Dental Students Association, UoM and Manchester Medical School, plus some of our own fundraising, we had enough. Hery had also managed to secure us research permits, and so after months of bureaucratic uncertainty, we were on. We booked flights, and had just a few weeks to finalise everything.
The last month before we left was manic. We delegated roles to ensure everything was covered: I was research lead – amongst other things I had to source antigen-testing kits from South Africa, urine filtration kits from Seattle, and malachite green which was crucial to the methods but excruciatingly difficult to get hold of. Hannah was medical officer, so after attending a 4 day expedition-medic course, had to assemble our extensive medical kit and Anthony finalised everything to do with logistics and money. This was all done amidst exams, dissertation hand-ins, and moving house. Steve had managed to secure a mini-hospital’s worth of donated drugs from East Lancashire Hospital Foundations Trust, to take to the health centres in the villages we would be working in. By the time we left we had surrendered ourselves to having surely missed something, but stepping on the plane felt fantastic and we were on our way.
Meeting and Greeting in Antananarivo
Touching down in Antananarivo (‘Tana’), we were abruptly thrust into the bustle of Malagasy life, as we spent our first week taxiing around the sprawling capital (the name means ‘city of a thousand hills’) meeting the people who we had spent over a year emailing.
The first of these was our primary contact, Dr Alain Rahetilahy, head for control of infectious tropical diseases in Madagascar. He met us in the main city square and took us through the thronging marketplace to his office, where we finalised research methods, and arranged the retrieval of 4000 tablets of Praziquantal, donated by the WHO.
Another taxi led us through the side alleys and up a steeply cobbled hill to the Durrell office, where we met Richard Lewis, Head of Durrell Madagascar, and Hery, to finalise our itinerary and logistics. It felt like a real honour to be in the headquarters of such a prestigious organisation. During the wet season, some of these areas are completely inaccessible, and we were cheerily informed that Marolambo, where we were headed, is the most isolated of the Durrell projects.
Day two involved a meeting with the Director General for Health, who seemed positive about our plans, approving our project and signing our permits. Another taxi (these were almost exclusively creaking 1960s Citroen 2CVs, often with a 2l coke-bottle below the dashboard acting as a fuel tank) took us to the University of Antananarivo to meet the Dean of the Medical Faculty, Professor Luc Samison. He introduced us to four medical students and doctors, whom we interviewed, and selected two to join the team, Daniel and Anjara.
The final few days were spent rushing around Tana, tying up all our loose ends: buying a generator to power the microscopes, picking up maps of the area, sorting out Daniel and Anjara with rucksacks, sleeping bags, and waterproof jackets, and trying to cram up on Malagasy.
Getting to Marolambo, By Hook or By Crook
Having spent a week driving round the bustling city, we were raring to get out into the fresh air, so leaving Tana was a relief. We hired a taxi-brousse and driver to take us, Dr Alain and our kit down to Mahanoro, a small sleepy town on the Indian Ocean about 250km from Tana. This was a gorgeous place to spend a few days soaking up the sea air. Durrell’s annual conference was taking place in Mahanoro over the week, so we were introduced to the local powers – the Environment Minister, the Education Minister, the Transport Minister and even the Mayoress, resplendent in a vivid purple dress. After a small final speech in my rusty French, we were given their blessing, and talked into the night with these inspiring people from all over the region who were all extremely passionate about their country. We bid au revoir to Dr Alain, who had become a grandfather-esque figure over the past weeks, smoothing all introductions with his humility, and initiating us to Malagasy with his insistence on karaoke sessions.
The next leg was to get to Marolambo, where our work would start. For this we had to hire a truck to take us up a jungle track into the mountainous interior, a journey which took us two full days. After an exhausting trip, we woke to a misty morning, looking down on the town from the priest house. Marolambo lies at the confluence of two rivers, surrounded by low-lying hills. Its painted-concrete town hall and cobbled streets gives an air of faded colonial grandeur amongst the corrugated-iron and wooden shacks lining the streets.
The Business of Schistosome Identification
We were looking for schistosomiasis by three different means – 1) looking for eggs in stool samples 2) looking for eggs in urine samples, and 3) testing urine for an antigen given off by all schistosome species. In addition to this Daniel and Anjara delivered an education programme to the schoolchildren on how to reduce the risk of schistomiasis. We also conducted interviews with local healthcare professionals, village chiefs, and headteachers, to discover more about attitudes to the disease, and to ask what interventions could be made to reduce its burden.
A typical village visit was as follows:
Day 1 / Introductions, distribute and collect 80 urine and 80 stool containers (it still amazes us how the kids managed to have all containers returned and filled within 20 minutes), carry out education programme, analyse urine samples under microscope
Day 2 / Prepare stool slides, start analysing stool slides
Day 3 / Finish stool slide analysis, clean all sample pots and slides, explore if time.
Smearing poo onto slides for 12 hours one in every three days isn’t everyone’s idea of a university summer well-spent. There were tactics to dampen the smell, but even with liberal Tiger Balm under our noses, it was pretty grotty work. Despite the smell, we managed to appreciate the unusual situation, and were even a little sentimental as we smeared our final stools, after three weeks and over 500 samples. The smell didn’t deter the kids, who were fascinated enough to spend whole days watching us through slats in the walls, as we smeared away, dreaming of pioneering an expanded Bristol Stool chart.
Once we had the results, we gave headmasters and the health centres the list of infected children, and instructed them to collect their free treatment of Praziquantal. As students, we frustratingly weren’t able to get permission to actively distribute treatment, so it was difficult to ensure that the children received the treatment they needed.
Once the work in the villages was finished, we managed to charter a plane from Marolambo back to the Tana, a journey of 39 minutes, compared to the four days it had taken us to drive there. We spent a week in Tana to write up the project, and met with Dr Alain to discuss our findings, followed by a final karaoke session, before flying back to the UK.
What Did We find?
Over 90% of the children that we screened had schistosomiasis. We found extremely high egg counts, well above the WHO threshold for ‘intense’ infection. On discussion of these results with experts, it is likely that children with this level of infection will be dying of the disease. These data vindicates our working in the region, demonstrating the need for follow-up projects.
What next for MADEX?
Our long-term goal is to reduce the level of schistosomiasis in the Marolambo region.
Reducing schistosomiasis in a population is difficult. The treatment is only effective until the individual is re-exposed to the parasite, so the recommended approach is to treat the whole population with Prazinquantal, every six months, until the level of infection is reduced. However, limited resources and the remoteness of many of the regions makes treatment really difficult. This is especially true in Marolambo where the people’s lives are inextricably linked with the river, meaning they are constantly re-exposed.
By advising MoH Madagascar of our findings, we hope to ensure that treatment is implemented in the region. In addition to this, with follow-up we also aim to reduce the disease burden by focussing on improving education and working with both the community and Durrell, to make interventions that will reduce exposure to the parasite.
This will hopefully be a long-term project, and to continue the collaboration between the universities of Manchester and Antananarivo. Planning for an expedition in summer 2016 is under way.
What Did We Learn?
Madex was a brilliant experience. It opened our eyes to the world of research and the possibilities of medical work in remote, unknown places. Being entirely responsible for a project and coming away with useful data has been very rewarding. We can’t wait to return, and try to ensure that the community really benefit from our work.
These are some of the most flagrant clichés going, but they held true for this expedition:
If you don’t ask you don’t get / It seemed bold to email the Ministry of Health Madagascar out of the blue, but there’s no reason why not to, and the worst that can happen is they say no.
Persistence pays off / There were a lot of barriers to this trip happening, but our determination in convincing people that the trip was worth their investment of time and money eventually worked.
Team attitude is the most important part of an expedition / Diarrhoea and vomiting from three weeks of dubious rice, or digging out dust-fleas from your feet with a scalpel, could ruin a trip for some, but if there is a positive attitude within the team, these difficulties can be turned into ‘experiences’ and dealt with.
Relationships with locals is crucial / Without Durrell and their contact with the communities, we wouldn’t have been able to work in these remote villages.
In-country team members help massively / We hadn’t anticipated how much help Daniel and Anjara would be. As well as translating and interviewing for us, they bartered prices, kept us aware of cultural sensitivities, and were just brilliant just to spend three weeks with, teaching us so much about Malagasy beliefs and customs.
You don’t have to have experience to be taken seriously / We had no prior experience of tropical diseases or microscopy, but we stuck to our methods and our findings are being used by MoH Madagascar, and are being considered for publication.
M’ora m’ora / The Malagasy way of life. Everything starts late, takes longer, and ends later, but everyone is so un-rushed and relaxed. We came away more relaxed ourselves, and wishing that life in the UK could follow suit.