Susie MacDonald / GP / UK
Upon completion of her training, and in pursuit of a short adventure which used her medical knowledge, Dr Susie MacDonald swapped middle England for Madagascar. With no more than a fortnight to try to make a positive and lasting difference, she describes the challenges and limitations of practicing ‘modern’ medicine in a place with few resources and an entirely different culture.
Madagascar and Me
I had not long qualified as a GP and desperately wanted to use what I had learned. With some time on my hands, I looked into arranging a trip to a low-resource setting, where my knowledge and skills might be useful. Ideally, it would be somewhere I’d always dreamed of exploring, with mysterious creatures that couldn’t be found anywhere else on the planet, with blue seas and white beaches. And crucially, it had to be somewhere I could actually be of help. Madagascar was all of these, and a lot more besides.
Madagascar is the fourth biggest island on earth. Due to its relative geographical isolation off the east coast of Africa, much of its flora and fauna exists nowhere else on earth. It is defined as a low-income country, ranking 154th out of 188 countries in the United Nations 2015 Human Development Report. Poverty in Madagascar is increasing and today 72 percent of the country’s estimated 22 million people live below the national poverty line.
Chronic malnutrition, and its associated illnesses, affects 47.3 percent of children under five years of age. Natural disasters can be blamed for some of this, as nearly a quarter of the population live in areas vulnerable to floods, cyclones and drought. However deforestation due to the use of wood and charcoal for cooking, and poor land management such as the “slash and burn” method, have led to the destruction of 85% of the rainforests and further food insecurity.
More than five years of political crises between 2009 and 2013 have had a disastrously negative impact on economic growth and development efforts. Corruption at all levels compounds this.
The Adventure Begins
My husband, James, is an Army officer who managed to be granted a sabbatical from his duties. We arranged to work, through the charity Edge of Africa, in a village on the South Coast: Analapatsy. It was a three-hour drive away from the nearest town, bouncing through dirt tracks, mud and sand, through flooded parts of the road that resembled lakes.
I had been a little suspicious of the vehicle we were in and its owners from the start. They were apparently friends of our translator, but their bus’ safety specifications left a lot to be desired: there were none. There were no seatbelts, although I’m not sure how useful they would have been as the seats themselves were not attached to the floor. The floor was rusty enough to put a foot through and the windows were stuck shut. I found my thoughts flicking between the thrill of the adventure we were embarking upon, and visions of us being trapped inside the minibus and burning alive.
Just when I thought I couldn’t take any more of the ear-hammering afro-pop from the stereo, and my legs were forever going to be stuck in what looked like a birthing position thanks to the luggage and supplies stowed under my feet, our relative peace was interrupted by a loud bang. A flash of flame rose up from the gear box near my toes, and the bus filled with smoke. Fortunately, it seemed that this was not the first time our drivers had experienced this hiccough with the engine, and somehow managed to get us moving again within half an hour. I can’t say that I was all that excited to get back in.
Analapatsy gave us an opportunity to see how most Malagasies lived – rurally, in wooden and straw huts, with little or no infrastructure to be seen. Our accommodation for the next fortnight was our tent, and we were given the great honour of being invited to camp in the compound of Analapatsy’s mayor. He, his two wives and various children and grandchildren lived in this dusty enclosure, accompanied by dogs, geese, chickens, cats and oxen.
It became pretty clear that staying well for the fortnight was going to be our biggest challenge, as infection control was not something that entered the minds of our hosts. Instead of asking for medical advice, when the children got diarrhoea they asked our interpreter to bring antibiotics back from the city for them. (Although remembering how my family and many of my patients ignore my medical advice, this made me feel quite at home.)
The villagers had been built five concrete latrines by an NGO a few years ago, but these were left unused. Their belief system required them to leave their faeces uncovered: as they buried their dead, they did not want to give the same respect to both. Instead they would relieve themselves in the fields, or anywhere around the compound. The area we were given to set up our camp was a rubbish heap which we, along with some children, moved and swept. Despite this, we were never far from human and animal excrement or detritus.
We were only the second group that the charity had organised to visit the village. Our presence caused a stir wherever we went, and we were fortunate enough, as we wandered around the village, to be met by welcoming shouts and warm smiles, as well as curious glances and excited children. It helped that we were joined on our trip by two interpreters, who spoke Malagasy (the local language), French (the official language) and English. That first evening we walked a mile over oxen-pastures down to the beach, and were able to wash off the grime of the road and the camp in the powerful waves of the Indian Ocean.
Straight to Work
The next morning, our work began. James went to the secondary school to help with teaching, and I joined the doctor in the clinic. Interestingly, the first thing he did was try to sell me a lobster, out of season. “It it always the way with you foreigners,” he said in Malagasy, “you are planning for tomorrow, we think only of today.”
It was some time before I discovered that he was not a doctor, but a nurse or clinical assistant. The villagers called him “Doctor”, however, and they respected his advice. There was certainly no shortage of demand, with a long queue already waiting for us as we arrived. They came with all the normal problems: coughs, back pain, sore throats, tiredness, and a lot of gastro-intestinal upset. There were also fevers, most commonly malaria, and for the first week I was there the clinic had run out of point-of-care testing kits, leaving the diagnosis down to guess-work and “treat and see”.
Malaria – the fight continues
Madagascar sees 27 in every 100,000 citizens die annually due to malaria, and immeasurable effects on economic and social welfare.
We were lucky enough to be in Analapatsy during the annual distribution of government and aid-funded mosquito nets. We listened as the Mayor, our host, explained the penalties for using the nets as fencing for livestock, on their farms, or for fishing. We were delighted to see women from all the surrounding villages arriving to collect their nets and were hopeful that these were going to be used for their true purpose, but there was really no way of knowing. It would only be with repeated education and encouragement that a change in behaviour would arise – beyond our scope in the fortnight we had in the village.
During consultations with patients with possible malaria, I was keen to ensure that they were asked if they had and used their mosquito nets. Most families had them, but not all the family slept under them. I noticed that within a few days of me repeating these questions, my Madagascan medical colleague began to ask these questions too. I could see change happening in front of my eyes.
For the want of a tongue depressor
On the second day a 12-year-old girl was brought to the doctor with a fever. She spoke like she had a hot potato in her mouth. The doctor was about to hand over some malaria treatment (for a fee), so I asked to look in her throat. This prompted a hunt for a tongue depressor, which resulted in a metal spatula being unearthed from a seemingly untouched Unicef box. Her tonsils were huge and covered in pus, and he seemed very interested in this examination as though he hadn’t seen it before. The treatment was discussed and she left with some antibiotics.
This was a moment to realise that my bread-and-butter was entirely different to his, and to gather how much we could learn from each other. The next week I returned with a box of plastic spoons for him to use as tongue depressors. Who knows if they were ever used? They may well be collecting dust like the instruments donated by Unicef.
Back to basics
Diarrhoea, often bloody, with abdominal pain, malaise and fever, was a common presentation. When questioned, patients would have blank faces when asked about using latrines, hand-washing, or ensuring the water that they and their children drank was clean. I watched the doctor consulting for days without ever seeing him wash his hands, despite there being a Unicef bucket with a spigot in the corner of his room. He said it was because it was on the floor, and difficult to get to. So we asked a local carpenter to make a raised table for the clinician and the midwife. Over the next few days I saw him use it a few times a day. Such a satisfying improvement in patient care, and visual education for the patients coming to him for advice.
However, useful change is easier said than done – the water was still the same water which the whole village collected from a bilharzia-infested sludgy waterhole a mile away. If there was a system for collecting rainwater from the roof of the clinic, then a safe and readily accessible supply would be assured. I wish I had had more time to work on this, but perhaps it is something for future volunteers to focus on. Perhaps, also, they could extend the “tippy tap” system that we set up at the mayor’s compound, which we used for washing our hands. It seemed to go down well with the children, even if the adults thought we were mad. They laughed and shook their heads as we used it – “crazy foreigners, who think that washing their hands is a sensible use of time”. We tried to convince them that it could save their children’s lives, but we were swimming against the tide. Any change of attitude will take time.
Contraception and delivery rooms
Family planning was something that was done very well at the clinic. The midwife was a well-trained, motivated woman, with a reasonable supply of contraceptive injections and pills. Every afternoon there were a handful of women attending her clinic, who seemed very happy with the free care they were getting.
The other side of this story, however, were the many young girls, often aged 12 or 13, who were married as soon as they started their periods and swiftly became pregnant. In this area, a girl was required to produce a child in her first year of marriage or her husband could reject her, and she would be virtually unmarriable from then on. This practice led to many complications, such as growth-restricted babies, obstructed labour and predictable consequences for the women afterwards such as fistulas and incontinence.
The delivery room in the clinic was horribly ill-equipped with only a dirty bed coated in grime, and walls smeared with brown and red marks. The few instruments were never washed and the midwife admitted to losing “some mothers and many babies”. There were sterilisers, but these were meant to be fuelled by a kerosene stove, which had sadly been taken by the previous doctor to use for cooking. Other options, such as boiling the instruments over a wood or charcoal fire, had not been explored. We discussed this huge topic, but were just too short of time to work on a solution. Another something for future volunteers to work on.
Overdiagnosis and overtreatment: a global problem
The clinician, with whom I was working, diagnosed a large number of patients as hypocalacaemic, without access to blood tests. He prescribed and received payment for countless packets of calcium supplements. Every patient left his room with at least four different medications. Often paracetamol and vitamin C tablets, which did not seem unreasonable for many of the conditions, but there were many other tablets sold for which I could see no clinical justification. Antibiotics, in particular, were used for many illnesses which we would consider are most likely to be viral. Other doctors I met in Madagascar over-prescribed in a very similar fashion. The clinician explained that patients in Madagascar expect multiple prescriptions from a doctor, and consider a consultation to be unsatisfactory if they leave with fewer than four medications. I could see this reflected in my own practice at home, when antibiotics are demanded, and can understand a reticence to spend valuable time explaining why no medications are required rather than prescribing and moving on. This would be particularly tempting when the patient is paying for the medications.
The problem was compounded by the availability of medications, and antibiotics in particular, to the public. At the local weekly market, alongside the vegetables and meat, were stands selling all sorts of tablets. Patients would present with the mildest of coughs having taken two days of amoxicillin already, or some other, less appropriate antibiotics. All making diagnosis and treatment more challenging.
I tried hard to educate the patients and the clinician about how basic hygiene, clean water, a nutritious diet and self-help measures are more useful than polypharmacy. I’m not sure how much of this information was taken in.
At the secondary school where James was teaching he discovered early on that the children had no toilet facilities whatsoever. They relieved themselves in the surrounding fields, or in a small wooded area which held the tomb of a village elder. The mayor agreed heartily that this situation was unsatisfactory and was keen to be part of any solution we could arrange. We found a plan for a wooden latrine on the WHO website, did some calculations and determined that a hole 3m x 2m x 3m was required to last 3-5 years. We set off to the city for the weekend to buy supplies and on our return found that the hole was completely dug. “By whom?”, we asked the teacher. “The children”, apparently! They showed it to us proudly at the PE session on Monday morning.
Needless to say, we felt pretty guilty, but it did show that they were keen for this latrine to be built. The local carpenter agreed to build the structure, so long as he was helped. In a well-attended parents’ meeting, the parents organised a rota for them to assist the carpenter on different days. By the end of the week the latrine was nearly finished. Since then we have heard that it is completed and, in contrast to the previous charity-built toilets, in use, which feels wonderful.
This trip was short, with just two weeks in Analapatsy village, but I feel we fitted a huge amount into our time there. I learned a great deal about working in challenging environments and the medical problems which present in these areas.
A surprising eye-opener for me was that as a qualified GP, I have so much more knowledge and experience than I realised. In this respect, education is the greatest and most sustainable gift that we can give. Seeing Unicef equipment languishing in the corner of filthy consulting rooms, and latrines unused in the family compounds, was a stark reminder that without some development of ideas and beliefs, improvement of health in the area was stagnant. This is why I didn’t see patients alone, but with the local clinician. By working together on each case we learned from each other, and created, I hope, some lasting changes.
Learning points and top tips
Be savvy / We went through a South African-based charity, Edge of Africa, and were attracted by the opportunity for James to teach and me to work clinically in the same place. The charity, it turned out, focused mostly on its Gap Year project in South Africa, and the Madagascan arm was very much in its infancy. We paid £2000 for what turned out to be a couple of days of unsanitary accommodation in the town, and our interpreters. Be aware of what is being provided for you when you pay an intermediary company; or organise it yourself. Madagascar was, however, a good choice for clinical work, and there is no complex paperwork barring clinicians from other countries working there.
Be safe / The infrastructure in Madagascar is worse than any African country I have ever visited, so be careful and allow time (usually days) for any travel. Flights often don’t take off, and roads are frequently impassable. We were on the south coast, which is a 3-day (which can become 7-day) journey from the capital city. We flew, but this is expensive (£280) and not very reliable.
Be helpful / Don’t underestimate the value of the education you have received. Even as a medical student, your knowledge of disease prevention and nutrition will stand you in good stead to help with most of the main issues facing people living in rural Madagascar today. We are very privileged to have this knowledge, and should not be shy to pass it on. It is more likely than any “wonder-drug” to save a life. However, always learn from and work with the people you are staying with. There’s only so much you can do in a short visit, and to create sustainable, genuinely helpful change, requires mutual understanding and compromise.
UNDP Human Development Report 2015: available at: http://hdr.undp.org/sites/default/files/hdr14-report-en-1.pdf
UNICEF Madagascar Health Statistics: available at https://www.unicef.org/infobycountry/madagascar_statistics.html#113
World Food Programme, Madagascar Overview: available at https://www.wfp.org/countries/madagascar/overview
All photographs were taken with consent of the subjects.