Salama Tana


As we checked into Manchester airport for Madagascar, we got some odd looks. The man at the desk did not even known that Madagascar was a real country.
I understood what he meant. Despite the many months of preparation for this trip, Madagascar had been this far off place; I still had no idea what to expect. 20 hours of traveling later, including a moment of panic when our plane’s destination was announced as Mauritius, we were over Madagascar. From the plane we could see the landscape laid bare by years of slash and burn farming, dotted with coloured roofs and the circular ditches that defended ancient farmers. We landed in Antananarivo (or “Tana”). Its name, translated as “city of a thousand hills”, is an apt description, with steep terrain crowded by small brightly coloured houses, stretching for miles. After a white-knuckle taxi journey we arrived at the hotel Tana-Jacaranda, and could finally relax.

We are a team from the University of Manchester, England, consisting of Dr Stephen Spencer and medical students James Penney, Hannah Russell and myself, Cortland Linder. We have come to Madagascar to study and treat a disease called Schistosomiasis. During our expedition, we will be assessing the burden of disease in children and also running educational programs to teach children safe hygiene. Although our trip is just beginning, this is really a culmination of a project that has consumed the full year. We have passed the intimidating Manchester ethics review board, planned our scientific methodology and expedition logistics and collaborated with the University of Antananarivo and the Department of Health, Madagascar. Our project has been funded and supported by many people and organisations, without whom this expedition would not have been possible. We are really grateful for their help.These last few months have been a bit manic, each member juggling expedition preparation with work while more and more unforeseen difficulties arise. However, with help we have somehow managed to get everything together in time.


James and I have flown out to Madagascar first to establish contact with the Malagasy team members, interview and recruit medical students, and buy anything we forgot. This will keep us busy; we’ve focused so much on bringing the kit we have left some pretty basic items behind. Preparing to barter hard for nail clippers and toothbrushes. This leaves little time to sightsee, but there is no better way of getting to know a city than by working in it. We are finding our way round, communicating in a mix of French, English, and even a bit of Malagasy (For those who’ve read this far, “Salama” means hello… thats about our limit). As we go, we consistently discuss and refine our research methods and educational programs, as we really want our project to be enjoyable for the children. Everything must be prepared by Thursday. Steve, Hannah and another doctor Steph will arrive in Tana and we will be off almost immediately into the field.
But for now, thats all folks!
Check in soon,


Reflections on the River

I was sad to see Hannah and Steph go. They have been extraordinary members of the team and we all felt a little bit empty after they left. However, our schedule was tight and researched continued, while we slowly settled into Vohidamba.

One of the most common topics of discussion during these weeks has been quality of life for the villagers. The landscape is so immensely beautiful that it is easy to idealise the people here. Vohidamba, for example, is a village of about 300 wooden huts huddled on a floodplain that backs on to a steep hill. In the evening, one can see smoke from hearth fires seep through the thatched roofs, splitting beams of a setting sun. Around the village, the Nosivolo River winds, passing into the west as a golden, sunlit streak specked by little green islands, cutting its way through giant forested hills. This is the background of daily life for all the villages, a stunning mix of extreme isolation and beauty.

Fields near Marufatsu

However, it is clear that problems run deep and occupy much of daily life. Houses are small, often crammed with several generations of family, and without electricity save the odd solar panel. Even in Marolambo, the central town, electricity depends on fuel import and road condition, meaning there is only 4 hours of electricity a day. During our stay, roads were so poor that the town was without electricity for 5 days. Access to clean water is also limited. In most villages there are taps with spring water, but these may be a 5-10 minute walk. In Ambohitelo, spring water was more than 15 minutes walk away; with the Nosivolo running directly next to the village, it is not surprising that most villagers drink and bathe directly from the river. Furthermore, although rice and bananas are abundant, meat is rare and most are malnourished. General health is poor, education is limited and in this isolated area, one doctor cares for 12,000 people.

Nevertheless, people here do seem to be happy. Even the sternest-looking Malagasy will crack into an enormous grin on greeting. There is an extremely strong feeling of community. Each village has both an elected chief and a Tangelamana, or village elder. Both are highly respected and run all village affairs, creating a unique blend of ability and wisdom. Everywhere, guests are treated to long greetings and unending warmth and generosity. At one point, a chief even slept with us in our hut, as his wife and children were spending the night in another village. As everyone knows everyone else, families and villagers look out for each other and crime appears to be low. During our trip, we were robbed on two separate occasions. However, both times, items were returned by chiefs or relatives within a day. Indeed, during our first evening in Ambohitelo, the robber was dragged into our hut by several other local boys, tried by the village elders, tied up and taken back to Marolambo, all before 11pm. Although sometimes unsettling, we feel privileged to witness village affairs and politics so rarely seen by outsiders.

Village Tangelamana

Our work in Vohidamba finished, we proceeded on to Betampona, the most isolated village of our trip. On arrival we were joined by one of the Malagasy students, Elodie, and her guitar. It was quite an entrance, within about 20 minutes she had every child in the village singing their hearts out. Most interesting was a song that encouraged the children to wash regularly. Our first night we went to a town party, where we danced inthe local Malagasy style with two drunk policemen. It was a strange experience. The 3 days in the village passed quickly and are honestly a bit hazy for me as I was sick on one of them. Before we knew it we were hiking the 25km back to the central town Marolambo.

We spent a week in Marolambo, researching and treating children in the nearby village Ampasimbola and Marolambo itself. Having been living for the past two weeks on rice for breakfast, lunch and dinner, we were spoiled in Marolambo. A hearty breakfast of rice cakes, pastries and battered bananas was normally found in a wooden stall run by Madame Olivette, a Malagasy realisation of Molly Weasley. For dinner, we ate at Chez Martin, the only restaurant in Marolambo. How the cook, a hardened pregnant lady, could produce hundreds of delicious Zebu brochettes and shredded Papaya in such a remote area is a mystery. With one glazed, immobile eye, glistening with sweat and wearing only an apron, she laboured over glowing embers in her dark, lean-to kitchen like a hardened blacksmith in a forge.

Steph is continully mistaken for a Malagasy

As our expedition comes to a close, we often discuss the future of the Madex project. Our goal is to continue testing the burden of Schistosomiasis in the region, while establishing sustainable projects to reduce the disease. Regular Mass Drug Administration (MDA) is effective in reducing Schistosomiasis, but cannot operate alone. This was highlighted during the MDA in Ampasimbola, when only 30% of the children turned up to be treated. Although this was more than 100 children, we were disappointed after the 70%+ attendance rates we had seen in other villages. We later learnt that the chief of the village did not properly inform the villagers of our work. Furthermore, many of the families in the village were either unaware of the risks of Schistosomiasis or suspicious of the treatment. It was clear to us that the lack of support from both people and leaders of this village stemmed from insufficient education about Schistosomiasis. With Ampasimbola behind us, we approached the MDA of Marolambo more thoroughly, and we managed to treat 900 children in a single morning. This was very rewarding and reaffirmed our optimism that our project can succeed. Nevertheless, the experience in Ampasimbola has contributed to our growing comprehension of the immense importance of education. We plan to expand Schistosomiasis education in future expeditions, not only to compliment MDA, but to ensure sustainable efforts to reduce Schistosomiasis after the Madex project finishes.

Finally, after 3 weeks, it was time to say goodbye. It had been an extraordinary journey, helped every step by amazing people. I enjoyed my time immensely and was fervently hoping for our plane to be delayed. Unfortunately, it arrived, and our bags packed, we hiked up to the small landing strip, which lay on the plateau of one of the taller hills. A rainy day; mist lay on the Nosivolo valley, with only the tips of forested hills from the other side of the basin reaching through the clouds. As the plane landed, we had a lasting image of five villagers, walking away over the crest of the plateau, their faded red patterned umbrellas sharp against the white mist. 40 minutes later, we were back in Antananarivo.

Hopefully we will be back soon!


Campfire songs and Culinary discoveries

Woke early and walked to Marofatsy’s water source; a longitudinally-cut piece of bamboo used as a half-pipe to create a ‘tap’ from the slow stream running near the village.  I enjoyed the walk to get water as it was a opportunity to take in the beautiful views.  Met an elderly lady washing her clothes there and marvelled at the conversation we were able to have despite speaking very different languages.  Amazing how much you are able to ‘discuss’ with only body language and a handful of Malagasy words.

After chatting about the weather and how slippery the paths were, I climbed the hill back up to our hut.  I hoisted the bucket up above my head and attempted to look as though I carry heavy loads on my head everyday… don’t think I fooled the locals.

We finished analysing the village’s poo samples under the microscope and packed up to leave.  A stunning 3 hour walk along the Nosivolo River took us to Vohidamba; the next village in our adventure.   We crossed the large river on a pirogue and were swarmed by children cheering ‘MadEx, MadEx’.  It was quite an overwhelming welcome to the village.

After making our introductions to the chiefs and headteacher etc, half the team began the education programme whilst the others set up camp in one of the small classrooms.

As it turned dark, we wandered over to the open fire a few metres away from our hut.  Four lovely ladies were cooking for us whilst having a good giggle and what sounded like a bit of a gossip.  We joined them and exchanged English campfire songs for Malagasy ones.  The stars were unbelievable and it was a really special night.

That evening, we learnt how these villages made the sauce for the chicken we were served; the chicken’s blood, feet and head were added to the rest of the meat for extra flavour towards the end.  Absolutely nothing was wasted.  Huge contrast to life in the UK.

The next morning was the day that Steph and I were due to leave the expedition.  I needed to transform into bridesmaid in a couple of days for my cousin’s wedding and Steph had to get back for work.  We reluctantly said goodbye to the team and the village and began the long walk back to Marolambo.  I had the SD cards taped to the inside of my passport.  They contained all the photos and videos from the trip up to now and so were by far the most valuable things in my possession!  The 7 hour walk was a good opportunity to think about all that the team had achieved.

Firstly, what an achievement Steve.  For those of you who don’t know; Steve came up with the idea for this expedition and has since been relentlessly driven and ambitious with the project.  He deserves all the praise he gets for this work and more.  I’ve certainly learnt an awful lot from him and feel very lucky to have met him a few years ago.

James and Corty have been impressively balancing fourth year medical school and organising the entire project with Steve and they’ve done an amazing job.  I was particularly impressed with the news that they were granted ethical approval from a Malagasy panel in the University of Antananarivo after some intense questioning… all in French!

Steph joined the project as a research assistant and was incredible with all of the children there, such an asset to the team and slotted in perfectly.  Within seconds of arriving in a new village, she had all of the children giggling, singing, dancing… even as she pricked their fingers to take blood samples for the research.

I joined this year’s expedition with a month to go and brought the ultrasound element to the project after an inspiring introduction to ultrasonography on my medical elective.  We were fortunate to have support from SonoSite in the form of a fantastic portable scanner (i-Viz).  Extremely pleased to have decided to return again this year.

Finally, words can’t describe how crucial the Malagasy team members were.  Couldn’t have asked for a better team to work with.

It has been really special seeing familiar faces from last year and to have people recognise you and thank you for the work the team did last year.  Walking back through each village and seeing the children that have been treated for schistosomiasis as a direct results of the team’s work was a proud moment.

The project so far has been a resounding success.  Steve, James and Corty are due to return at the end of June.  They are all well and are working hard to perform all the research on time.

The project couldn’t have happened without a lot of help and support from many people.  It is difficult to name all here, but to all of you; thank you so much.


Blessings from Marolambo

I write from Marofatsy in the district of Marolambo, Madagascar.

James and Corty are analysing faecal samples under the microscope by candlelight. The  night air of the rainforest is humid there is a damp smell to match. Cicadas buzz smoothly in the background, whilst ‘Blame it on the Weatherman’ (by B*Witched) is playing from our small speaker.

The wet season in Madagascar is over the British winter. I was told in 2013 to avoid this season and so planned to come to Marolambo in May-June.

During the wet season in Marolambo, roads become un-driveble, and walking paths become muddy and arduous. Despite being here in the dry season, today was the first day it hasn’t rained and it’s been glorious!

We are as remote as can be. Hannah has spent the evening taking me through the expedition medical kit which has been planned to cover every emergency possible. It would take a minimum of 4 days (weather permitting) to reach the nearest hospital in the case of an emergency, so the kit really has everything in it up to performing minor surgery!

Since returning from Madagascar in June 2015, not a day has passed that we haven’t been planning every detail for this trip. It has been so worth it (even in the constant rain).

Prior to Marofatsy we visited the main town of Marolambo where we spent two days planning and meeting the chiefs (traditional chiefs, official Chiefs, medical Chiefs and school Chiefs). Sleeping in the Priest’s hut was just as surprisingly luxurious as last year (hot water and toilet with a seat).

We were joined by the village chiefs (official and traditional) and head teachers accompanied by many village faces looking through the windows. Dr Alain (head of Neglected Tropical Diseases in Madagascar) gave an introduction about our project in Malagasy, the Chiefs blessed the project, and the team and I warming thanked them for their hospitality.

Research day 1: education on schistosomiasis and hand hygiene preceded the study. We divided the school but into several ‘stations’ through which the fifty children (aged 5-14) would rotate through.

Daniel, Zo, Emmanuel and Dr Alain completed the questionnaires with each child (assessing the impact of schistosomiasis in their daily life),

Jamed and Corty measured each child’s height and weight, Hannah performed ultrasonography, and Steph and I took blood to test for anaemia and malaria.

We had hoped to run through 25 children each day but the first day  had gone much quicker than planned; we had only 19 children left for day 2 meaning extra time for faecal and urine analysis!

Our third and last day involved treating every child in the village for schistosomiasis via ‘mass drug administration’ as advised by the WHO. This was completed by Dr Alain and the Malagasy side of the team. Many pictures with the village and videos (including the use of a drone) were accompanied by the sounds of a hundred screaming children who had received their Praziquantel – this marked the end of Ambohitelo.

Three hours along a very muddy (but sunny!) route took us into the larger village of Marofatsy. A much more efficient day 1 of research meant that we performed research on all 50 study participants on the first day. Day 2 in Marofatsy brings us to the day of writing. Poo smearing in the morning was overcome by sunny weather and knowledge of a local waterfall (photos to come)! Well worth it and a very well received break! We have completed a third of our research and have 4 more villages, 200 more children to work with and we love it.

The reason Hannah has been taking me through the medical kit is because she will be leaving with Steph in two days to return back to England for other commitments.

Every child in Marolambo whispers Stephanie’s name – she is becoming the most well known person in the district. She even managed to make children laugh when they have their blood taken?!?!?!?

We are now in the swing of things, have gotten used to the long drops and feeling dirty, and can distinguish the different varieties of rice for breakie, lunch and dins (I must learn how then make it taste so smokey!). James and I are beating out initial infections and coming to the end of our courses of antibiotics and turning a corner health-wise. The team are all well, in great spirits, and having a really fun time. The research is filled with laughter amongst team, children and locals.

Everyday of work for this expedition was so so worth it. It’s beautiful, serene, peaceful and people are wonderful and their way of life is extremely humbling, an honour it is to be welcomed into these tribes and get a glimpse of how they function in one of the most isolated parts of the world.

I am so glad that both Stephanie and Hannah joined the expedition – the MadEx team and children of Marolambo have been much better off for it. Vohidamba, Betampona, Ampasinbola and Marofatsy to come, as we continue further into the bush.


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Taxis and tribulations


Madex2016 Blog

I’m writing from the balcony of our hotel Tana-Jacaranda, with a delicious cup of Malagasy coffee, using our first free morning of the week to update the blog. It’s warm, breezy, rumbling with traffic from the cobbled streets below. There is a beautiful hazy view, framed by giant bamboo and jacaranda trees, of the orange-pink stone Queen’s Palace, topping one of Tana’s thousand multicoloured hills.

Corty and I have spent the week meeting and greeting all our contacts here, finalising plans and making sure everything is set for our fieldwork before the rest of the team arrive this afternoon. Tomorrow we fly (weather-permitting) to Marolambo.

We’ve tried to walk around the city as much as possible, both to getting to know it and to minimising time in taxis. Generally the Antananarivo taxis, old Citroen 2CVs, are delightfully quaint – battered and clotted-cream coloured, with huge amber gearsticks and Malagasy phrases tattooed all over their interior – but one emerges from a short ride, slightly exhausted from the carbon-monoxide-laden cabins. We try to avoid them whenever possible.

Monday morning we met with Dr Alain Rahetilahy (Minister for the Prevention of Infectious Diseases) and discussed how he will accompany us for the first 10 days, helping supervise treatment for all schoolchildren in the villages. Monday afternoon we met the Dean of the Medical School, and interviewed a selection of final-year medical students/junior doctors to join us on the expedition. Many of them had a wealth of experience working in the bush (more than us!) and we would have been happy to take them all. In the end we selected students based on their English, and so will welcome Elodie, Emmanuel and Zo, along with Daniel from last year, onto our trip. They will help out with interviewing children and village elders and delivering an education programme to the children.

On Tuesday, we were faced with the intimidating prospect of presenting our project to the University Ethics board. After giving a 30 minute presentation in French to the board of 7 doctors and professors, we formed a more friendly circle and answered various questions they had on the project. Having to answer in French gave us a good excuse to ponder the more difficult answers. Overall we understand why the board quizzed us so thoroughly before approving the project; they must ensure a high standard of research and we pleased to have met their expectations.

Wednesday morning we taxied up winding cobbles to the Durrell Conservation Trust HQ, and met with Hery (Herizo Andrianandrasana, Ecological Monitoring Coordinator for Durrell Madagascar) and Richard Lewis (Programme Director of Durrell Madagascar). Durrell have been running a community conservation programme in the Marolambo region for over 15 years and it’s through them that we are able to work in the region. They have strived to make the Nosivolo river (on which Marolambo and the surrounding villages lie and home to 19 species of endemic fish) a protected site. Their ethos is to conserve the environment through supporting the whole community; Richard used ‘Healthy people, healthy river’ as their tagline. Through monitoring and improving the health of the villages on the river, we can contribute to Durrell’s aims. Working with Durrell is a real privilege; they’ve been doing fantastic work in Madagascar for a long time. Collaborating with them gives our project the chance to have a much bigger positive impact on the Marolambo community.

Corty is just back from printing 200+ sheets of permits/proposals/letters of approval to distribute to the mayors and medical chiefs of the villages (emails won’t do here, they love printed and signed documents – if it’s not in print, it hasn’t happened, much like instagram and photos back home) and we have a full afternoon of cleaning microscopes, packing bags, and rolling out the red carpet for the rest of the team arriving in a few hours.

Thanks for reading, and keep following us as we venture into the interior tomorrow…!


Madex 2015

In May 2015, Dr Stephen Spencer led a team consisting of the Manchester medical students Hannah Russell, Anthony Howe and James Penney to study schistosomiasis in Madagascar. Read more about their trip here.                                                                 

A journey of serendipity

A journey of serendipity

I write from an Arriva Trains Wales carriage, armed with a coffee and on my way to Herefordshire.

It’s taken a long time to get to this stage. We’ve fired off countless heavily caffeinated emails from Anthony’s living room over the past year and arranged meetings with experts all over the country. I have spent car journeys daydreaming about the trip (with James and Anthony warbling to a background soundtrack of The Lion King), but it has always felt like something that was a long way into the future.

And now, with three weeks to go, it’s all getting a bit real. Booking flights has made it feel like we’re going. I can’t believe we’re actually going.

Today I began to think about the things we’ll need out there. Number one on the list: passport. Aha, now that was something I hadn’t seen since February.

Feeling like a complete mug, I called up Her Majesty’s Passport Office to arrange a replacement; yet another lesson learnt from all of this. It’s easy to forget the basics and be swept away with impressive things like communicating with WHO leaders.

I’m spending the next four days on a course, learning how to be a safe Medical Officer for the expedition. It’s a course designed for doctors but hey, we’ve spent most of this process feeling a little out of our depth and it’s something that I have become quite accustomed to.

It’s been hard work, but now I understand what it takes to organise an expedition. I’ve developed those cliché CV-boosting skills, as well as the ability to compose comprehensible emails at 3am and reel off a three-sentence synopsis of the expedition in my sleep.

With Anthony’s self-assurance, James’ charm and Steve’s experience, we’re a pretty fab team. A team that has used the word ‘serendipitous’ so many times that I was forced to Google what it actually meant but wow, what a journey. Something I’d recommend to almost anyone… and we’ve barely even started.

Written by Hannah Russell (Medical Officer, Madagascar Medical Expedition 2015)

Leaving Manchester

Greetings or ‘Manaonu’ from Madagascar! We’ve made it as far as the Indian Ocean, and have a few days in the small town of Mahanoro before heading into the isloated district of Marolambo where our real work starts. The cyber cafe I’m writing from is a wooden hut on stilts, surrounded by chickens, children and dubious smells. Needless to say the connection isnt brilliant, the keyboard is pretty dodgy, and we want a stroll along the beach before the sun sets ever-so-quicklily, so heres a brief bringing of things up to speed.

The last couple of weeks in Manchester were completely manic. Finalising Madagascar came at the same time as all of the end-of-year activities – final exams, moving house, goodbyes, barbeques, parties and cricket matches which couldnt be missed. Around this we had to make sure all plans were watertight (or thereabouts). For me sorting out our methodology this included ordering urine filtration kits from South Africa, antigen testing kits from Seattle, and sending pots of staining chemicals to Madagascar via DHL special delivery, and I lost track of the host of other logistics that Hannah Steve and Anthony had to sort, from finalising permits, to working out where we could find a generator to lug around with us once in situ.

Finally the day came and we set off from Didsbury on Monday 8th June, leaving a post-parklife and pangaea Manchester.

My sister Ellie came to see us off at Heathrow, surrounded by our 9 enormous bags of luggage (looking like silk-wrapped hobbits in their protective clingfilm packing to avoid being tampered with enroute in Nairobi).

Very excited, pretty nervous, fairly confident we’d forgotten something, but also elated with the realisation that there was nothing more to could do until we landed, we had a last Cafe Nero chai latte before boarding the plane for the Land of the Lemurs.

Ciao for now, James

Handshaking with Antananarivo

We arrived safely in the capital city, Antananarivo, and into the comfortable hotel, Tana Jacaranda. A feeling of great relief, achievement following over two years of planning as well as a sense of excitement about the field work ahead.  First, we had four days of meetings as well as retrieval of a signed work permit!

Our first rendevouz was with Dr Alain Rahetilahy, the head of control of neglected tropical diseases in Madagascar, and our primary contact in Madagascar. We finalised our research methods and arranged the retrieval of 4000 tablets of Praziquantel (the treatment for schistosomiasis), donated by the WHO for our expedition.

Another taxi lead us through the markets and side alleys to the Durrell Foundatrion office. Here we met with Richard Lewis; Head of the Durrell conservation organisation, and his team, to finalise our itinerary and logistics for work with the people of Marolambo, where Durrell work in the Nosivolo river is highly active.  We learned that Marolambo is one of the most isolated parts of Madagascar, and the road to it; long and arduous!

Day two involved a meeting with the Director General for Health. Dr Alain introduced our team and project and after a couple of minutes her smile and signing of the permits felt like a huge milesteone finally achieved.  She expressed her desire to make this a long term collaboration and expressed the importance for a follow up expedition.

A short trip by taxi took us to the University of Antananrivo to meet the Dean of the Medical Faculty, Prof Luc Samison. He introduced us to four medical students/doctors who we interviewed, and selected two to join the team (Daniel and Anjana).

On Day 3, back to Dr Alain’s office to pick up four boxes of Praziquantel and he confirmed he would join us for the first leg of the trip – Andasibe and Mahanoro. We decided to split the team for the afternoon as increased efficiency was needed  in preparation for departure the following day. James and Anthony went shopping for the generator (needed to supply the microscopes) and remainng kit.  James and Anthony went shopping for the generator (needed to supply the microscopes) and remainng kit.  Meanwhile,Hannah and I took a taxi back to the Durrell office to confirm arrangements with the Malagasy students,introduce them to the Durrell team and buy a Malagasy flag for the tent!

For our final evening in Tana, Rob Gandola (Irish crocodile researcher) took us to a local restaurant where the ex-pats meet every Friday.

Getting the helminth out of Tana

We woke early and hopped into a taxi brousse. The driver played a tape with a mix of Malagasy and French songs, before the likes of Whitney Houston and Elton John took over.  We stopped overnight in Andasibe and squeezed in a night walk in the rainforest where we saw some amazing lemurs. Eventually, we arrived in Mahanoro in time for dinner The next day and headed to the local restaurant ‘J’adore’.  After a bite to eat, we joined in with some karaoke and had some good dance offs with locals. One of my favourite moments so far was when Dr. Alain took the mic to blast out a French song.  He told us that we we good dancers but I think he was just being polite.

The place we are staying in is called Tropicana. The sign at the entrance has a fantastic spelling mistake which describes it as a ‘Bungalove’ rather than a bungalow.

The next day, after a classic Malagasy breakfast (baguettes that disintegrate when you touch them), we left to meet the head of medicine for Mahanoro. Dr. Alain presented our plans in an attempt to win him over.  With so many introductions on this trip, we have learnt that meetings seem to follow the same pattern.  They begin with 10 minutes of stern faced interrogation before a critical moment when we deemed to have good intentions and are trustworthy. After this  moment, there’s an eruption of excitement and we are suddenly asked to come and meet yet more people.  We were taken to meet the head of education for the area and went through exactly the same process with him.

The next day, we met with the headteacher of the school in Mahanoro that we hoped to test. After briefly testing our intentions, she summoned 50 children to line up outside her

  office. They greeted us with a a group ‘bonjour’ and a round of applause. What a privilege. The head of education explained what we needed – a poo sample and a wee sample. The explanation was given in a fantastically over-the-top way, with brilliant actions to accompany his words.  The children found this absolutely hilarious. They must think that we foreigners are very odd, coming to Madagascar to collect these samples from them! We left sample pots with the children and they filed away back to their classes in an impressively ordered way.

I had shivers soaring through my body and struggled around the market in an attempt to help buy some vital things for our research. By the time we made it back, I was exhausted and had a pretty high temperature. I woke the next day determined to go to the school with the boys and help with day one of the research. It quickly became apparent that I was fooling myself and reality hit. It was really hard waving goodbye to the boys knowing that I’d be completely missing out on a day of research but a horrendous day in bed told me that it was the right thing to do. They returned and looked after me really well, very grateful to have them!

Fortunately back to good health today and ready to get stuck into work. Due to leave Mahanoro tomorrow and head into the extremely isolated Marolambo district for the bulk of the research.  Can’t wait!


The Hard Work Starts

Today we awoke bright and early to begin out first day of screening school-aged children for Schistosomiasis. We met the incredible headmistress of the school – Tanambao II in Mahanoro, the previous day to do the traditional malagasy introduction and stamping of documents.

CCA tests diagnosing Schistosomiasis infection.
CCA tests diagnosing Schistosomiasis infection.
Analysis of faecal samples under the microscope. Looking for elusive Schistosomes!
Analysis of faecal samples under the microscope. Looking for elusive Schistosomes!
Sampling urine with an audience.
Sampling urine with an audience.
The 25 year old guestbook of Tanambao II School.
The 25 year old guestbook of Tanambao II School.

We also deposited the sample pots for the children and the enigmatic Education Chief for the region gave hilariously clear instructions on how to get their faecal samples or ‘caca’ into our pots.

The day started with receiving these samples, and despite clear instructions of ‘pea-sized’ amounts of caca, some children felt inclined to be more than generous. The same was true for our urine samples – 10mls is enough, but the children thought it better to fill right to the brim!

The enigmatic Education Chief instructs the children on how to collect their samples!
The enigmatic Education Chief instructs the children on how to collect their samples!

Samples reluctantly in hand, we set up our research station in one of the schoolrooms. Imagine a fusion of Victorian school house and a slightly weathered tropical beach house and youll be on the right lines.

We delegated tasks, and with Hannah unfortunately running a 39 degree fever back at the hotel, we knew we needed to be efficient. Consent forms were signed and stamps, meticulous records kept.

We could put off preparing the faecal samples for Kato-Katz no longer. James and Stephen had run over the methods to the point of exhaustion – it was time to open the pots. With a sizeable dollop of Tiger Balm under the nose the boys spent hours preparing slides with a luminous yellow malachite green stain.

Meanwhile, I was in charge of urine for the day. 50 samples were prepared for a point-of-care CCA test (a Schisto pregnancy-type test) and the stopwatch was started. It was incredibly worthwhile to see the tests work, and whilst we knew this meant that some children were indeed infected, we could direct them to curative treatment at the local health centre (centre de sante de basse) that we had secured from the WHO. This was valediction for two years of hard work.

We plodded on testing urine samples for blood, looking at the faecal samples and performing CCA. I cannot deny that in the heat of the tropical sun – it was a long hard day.

Whilst the surroundings are beautiful, the fieldwork is most certainly not glamorous. The prize for hardest worker was rightly awarded to James who spent the last hour of day ‘recycling’ the faecal sample pots – i’ll leave what that entails to your imagination.

At the end of the day we submitted a list of students who had tested positive for Schistosomiasis to the headmistress who will direct them to curative treatment. We also signed the 25-year old visitors guestbook and in the traditional malagasy style placed our new MADEX2015 stamp!

We left the school exhausted, content and feeling pretty reflective about the sheer privilege that it is to do our work in this wonderful part of the world with these wonderful people.

The walk home, despite being laden with equipment and samples, was a pleasure! Looking on to a relaxed evening over our new favourite beer – Malagasy THB (the standard ice-cold bottle being 650mL for 40p!) – we started making plans for the next years expedition. We four have done what everyone said we would do, we’ve fallen in love with Madagascar.

Tomorrow we venture into one of the most remote parts of this incredible country for three weeks. With no internet, no running water, and having to carry our quarter of a tonne of equipment, it will be hard but hopefully valuable work.

Until the next time,


M’ora m’ora

We woke early to pack up our bags in preparation for leaving Mahanoro later today. On our way to the Cyber Cafe, we bumped into Bellarmin (our in-country contact who knows anything and everything about the Marolambo District) and he dropped the news that departure has been pushed back to tomorrow… Of course.
The Malagasy have a saying; “m’ora m’ora” which means slowly, slowly. We’re quickly learning that it’s impossible to stick to strict times here and even harder to plan anything beyond the next day. However, if you let yourself settle into the rhythm of life here, it’s quite nice really.
It’s a shame to postpone our journey to Marolambo as we are feeling eager to crack on, but I suppose it gives us some more time to prepare our kit for the upcoming research (and to fit in that walk along the beach that we are still yet to find time for).
It would be great to upload a detailed itinerary on here however the m’ora m’ora lifestyle makes it very hard!
Here is the best we can offer this morning:
20.06.15 Leave Mahanoro for Marolambo (who knows what time) in a truck. Have been told multiple times that the road is très mauvais and difficile and we often get a bit of a giggle from the locals when we tell them where we hope to go. The word ‘adventure’ has been used a lot.
21.06.15 Introduce ourselves to the leaders in Marolambo
For the next three weeks – sampling 2 schools a week. Will involve trekking between villages (in apparently the most isolated part of Madagascar) with all our equipment. Will take faecal and urine samples from children and use microscope to spot schistosomiasis (fingers crossed we manage to carry enough fuel to supply the generator for the entire time).

Last night, we went to the closing part of a big conference here. The leaders for the local districts came together to discuss various topics. James gave a great presentation in French to the delegates to explain our plans and we seemed to be very well received. We met our Malagasy team members (they had travelled from Tana that day); Daniel and Anjana and took them out for a meal. They seem fantastic and we are looking forward to working with them.
À bientôt, Hannah

An arduous road to Marolambo

We left Mahanoro for Marolambo at 10am last Saturday (20th June) in the back of a truck (cameon). We attempted sitting along the sides, gripping on the edges, but we were thrown from side to side due to poor road conditions and after 11 hours we were splayed out across the entire truck. Despite this, the journey was incredible with beautifulviews of the countryside and it was fascinating to get a glimpse of village life as we went further through the remote forest.

The team in the truck leaving Mahanoro.

The team in the truck leaving Mahanoro.


The drive did not stop here. Just past the half-way point (approximately 50/60km from Mahanoro) we spent the night in small wooden shacks of a hotel that lined the road.
The journey continued the following day at 7am and the ‘road’ conditions became progressively worse. 12km away from Marolambo, we came to a stop because a truck in front had crashed into a ditch, blocking the track. We found several willing porters to help carry all extra bags and equipment and hiked the remainder of the way, finally arriving in Marolambo at 9pm Sunday evening, (only slightly battered and bruised from the journey, but all healthy, well and happy).

The road to Marolambo

The road to Marolambo

Marolambo is a very special town. Surprisingly, considering its remote area and very very arduous road, it is relatively large and developed – it has a church, Hotel de Ville, and busy market.

Several introductions filled the Monday. We met the head teacher of the main primary school in Marolambo (which has 743 pupils), who randomly assigned 80 children to participate in our study. Bellarmin, the head master and our Malagasy student counterparts introduced our project to the children. Embarrassed faces emerged like a Mexican wave and we could tell the children had learned that we wanted their pee and poo! 80 faecal pots were handed out but it left 10 extra young children in the room in tears. Our study group increased to a sample size of 90.

Embarrassed and giggling school children being told what the study involves!

Embarrassed and giggling school children being told what the study involves!

Madex team with the 90 school children who were screened for schistosomiasis in Marolambo.

Madex team with the 90 school children who were screened for schistosomiasis in Marolambo.

Next stop was to the CSB, with Le Medicine Inspecteur de Marolambo – the chief doctor of Marolambo. She expressed incredibly kind words of gratitude and blessed our team for our work and for the donation of the medical supplies.

A ten minute walk took us to the opposite end of the town to the director of education in the area where we decided upon the next 5 schools covering Marolambo and the two villages, Marofatsy and Betampina.

The priest has a beautiful wooden house surrounded by a very well kept garden. Much like a palace, the building is situated at the highest point in Marolambo and expresses great grandeur. There is a spare room here with two beds and the priest kindly offered this room for us to stay in. The facilities are equally impressive – a shower with warm water and toilet with a seat! We were very very happy!

Unfortunately for me, the following morning meant saying goodbye to this beautiful and peaceful town, and more upsettingly, to my team. A 9 seated plane landed smoothly on a concrete airstrip 30 minutes walk from the town. I spent the next 39 minutes at the front of this small jet talking to the Swiss pilot of Mission Aviation Fellowship (MAF) who takes Charitable and Christian groups to and from various remote locations across Madagascar. We both agreed that flying is the better option and will be our means of transport for any follow-up expeditions!

View of Marolambo from the air. If you look closely at the top left, you can see a line of 5 white dots. This is the team in the school playground wearing their labcoats.
View of Marolambo from the air. If you look closely at the top left, you can see a line of 5 white dots. This is the team in the school playground wearing their labcoats.

Since my arrival in Antananarivo I have spoken regularly to my team. They have screened two schools in Marolambo. The first school had a schistosomiasis prevalence of 86.9% and second 92.5%. I met with the ministry of health today who are shocked by the very high rates and will start arranging for mass drug administration to treat the town of Marolambo for schistosomiasis.

Needless to say I am devastated to leave at this stage but I am proud and happy of the work we are starting in Madagascar and that my team have settled well in Marolambo where they are safe and in good spirits.


(Written by Stephen Spencer, Founder and Head of Madagascar Medical Expedition 2015)

We find our first schistosomes, what a fluke!


Having sadly waved goodbye to the 9-seater plane carrying Steve back towards Tana (a 39 minute journey compared to the 4 days drive to get here) we now had to pull our reduced team together and make sure we continued the good work.

Steve has been absolutely instrumental in this trip, and it’s essential that we pay him due credit here.

After becoming interested in schistomiasis on a medical placement to Egypt, Steve started firing off emails to WHO Madagascar and others over 2 years ago to investigate the possibility of research in Madagascar. Since then he has put in countless hours of work, in front of and behind the scenes, to make sure that the trip has continued to fruition. Whilst Hannah, Anthony and I have had our share of jobs over the last year, tailoring plans and finalising details, Steve has been there as a constant galvaniser, supplier of advice and reassurance for us, and string puller in all directions to make sure that everything came together. We’re so grateful to have had the opportunity to take on this expedition, and aren’t for a minute forgetting that without Steve none of it would have been possible. The only thing I’ve really seen Steve fail at is in gaining us access to the Gold Lounge in Nairobi Airport. ‘You have not been using your air-miles, Dr. Spencer!’ Ivory Lounge was the best that Steve’s measly air-miles could scrounge, and there wasn’t one in Nairobi, so back to standard non-AC lounge it was for us.

Anyway, eulogy over, but thanks so much, Steve, we’re all incredibly grateful.

I’m writing from Ambohitelo primary school, which is perched next to the village football pitch right on the banks of the Nosivolo river. For our 3 days here we’ve been given one of the school’s two buildings to double as both dormitory and laboratory. The schoolkids so far have spent their time playing football, performing a kind of elastic skipping rope game, or staring at us as we try to convince our microscopes to work, so we don’t feel too guilty for robbing them of a classroom for a day or two.

After Steve left Marolambo we had our first full run of slide preparation and microscope examination with the team that will see us through the next 2 1/2 weeks. A full sample of 70 kids’ poo and pee from Marolambo primary school was obtained, stained, and the entire next day was spent analysing these under the microscope. After initial frustration at the slowness of reading each slide, and worried that we wouldn’t have the capacity to continue with our planned sample size, by midday we’d found our rhythm and by the evening we’d gone through 70 slides and had identified our first really high schistosome egg counts. Coupled with the 90+% schistosomiasis prevalence found in the school by urinary antigen tests, these high egg counts indicate intense infection in the area. Whilst bad news for the community, this was confirmation for us that we had come to the right place in terms of looking for areas of high infection, where appropriate interventions could make a significant difference, and so to some extent, real vindication for us of the value of the expedition.

In each school, Daniel and Anjara, our fantastic team members from Antananarivo University, deliver an education programme to the kids about the nature of schistosomiasis and advising how to avoid it and other parasitic infections. They use the school’s blackboards, coupled with some brilliant posters from the UoM Immunology Dept, to emphasise the importance of how handwashing, hygienic eating habits, and awareness of the river as the harbour of schistosomiasis can reduce illness. It’s been very rewarding so far to see the kids really listening to and engaging with the sessions, and then also how parents and teachers will listen just as attentively from the back of the classroom, following up with questions and queries. As well as our additional supplying of drug treatment to the local health centres, we’re hoping that this will help reinforce the long term reduction in the amount of schistosomiasis in the region.

Since Marolambo, we’ve screened another 80 children in Ampasimbola primary school just 15 minutes walk and a log-canoe river crossing away, and have now travelled to Ambohitelo, our third school in the region, 1 hour’s walk up the river. Over the next 2 weeks we plan to screen three more schools, totalling 6 along the Nosivolo. Bellarmin, our envoy and organiser supreme from Durrell Conservation, has accompanied us so far, making the invaluable introductions to the village chiefs and headmasters, without which our work and integration in the villages would be impossible.

As I have written this in the dying light, Hannah and Anthony have gone through another 15 slides, Daniel and Anjana have done more brilliant work interviewing the headmaster on his perception of the health needs of the school, and the wife of the village chief has brought us a huge canteen of heavily cane-sugared coffee and a plate of mofokondro (battered deep-fried bananas), for which we are fast developing a taste.

It’s a constant privilege to work here. Everyone we have met has been unbelievably welcoming, it’s a fascinating culture to be immersed in for this short while, and whilst sifting through poo 1 day in every 3 isn’t everybody’s idea of a summer well spent, I wouldn’t swap it for anything.



50 shades of stool 

50 shades of stool 

We are starting to get into the swing of Malagasy village life.

We said goodbye to what felt like every person in Ambohitelo, and after gaining permission to leave from the traditional head of the village, began our walk to our next destination; Marofatsy.  The weather was perfect and the Nosivolo River was just stunning.

After introductions in Marofatsy, we were shown to the school.  The schools are made up of a set of wooden long houses and we were given the use of one for our research work and sleeping – we made sure that these two activities happened at opposite ends of the room!

The next day, we were woken early to the sound of children brandishing their poo samples – wonderful!  We collected the samples before heading to breakfast prepared by the head teacher’s wife… rice of course.  We were fortunately armed with our own condensed milk to make the soggy, wet breakfast rice just about palatable.

Then it was on with our day of poo smearing! I just love these days that come around every 1 in 3 days.  We have experienced such a vast variety of poo.  Feeling qualified to offer an improved version of the Bristol Stool Chart, we found ourselves wondering if the ‘MadEx 50 shades of stool’ chart would ever take off.

Apologies in advance for those not wanting to discover more, but to describe the basics of Kato-Katz smearing for those interested…

  1. Shut the windows to stop hundreds of children watching the strange activities of the vasa (directly translates to ‘white people’)
  2. Light incense sticks and apply Tiger Balm beneath nose
  3. Don protective lab coats and rubber gloves
  4. Set up some music to work by
  5. Take poo from pot with wooden stick, place on piece of paper, force a mesh on top and scrape away sample of filtered poo, place on slide within circular shaped template, lay cellophane (pre-soaked in dye) over slide and smear out the sample with Anthony’s old library card

It is such a glamorous a experience, one that I will be forever reminded of when I hear ABBA – this made up the majority of our background music (due to our Malagasy team members’ love of the group).

One of the best memories from Marofatsy must have been finding a couple of hours one afternoon to walk to a nearby waterfall with the leaders of the village. It had been a good few days since we last showered and so we jumped on the opportunity to swim in one of the pools there.  It felt like nature’s answer to an infinity pool with a 70m drop over the edge and a stunning view out over the lush hills.

The view over the waterfall's edge

The view over the waterfall’s edge

Swimming in the waterfall

Swimming in the waterfall


We have been looked after so well by the headmaster and his wife here, such a kind and welcoming family.

We completed the sampling and microscopy within our three days there and woke the next morning to fuel up on rice and deep-fried bananas before our walk to the next village – Vohidamba.



Sampling Malgasy life

Sampling Malgasy life

A river crossing in a hand-carved pirogue took us to the foot of the village of Vohidamba. As usual we appeared to be the centre of attention, though this time the centre of thousands of people’s attentions; Vohidamba is a large village.

All eyes on us as we arrive in Vohidamba

All eyes on us as we arrive in Vohidamba

We began the usual process after introductions: hand out urine pots, receive filled urine pots and then exchange them for stool pots and a sweet, expecting to be in possession of stool samples by the following morning.

This time was different though; within about 30 minutes, all the children apart from one had managed to produce a sample and return it. As if the entire school should produce a stool sample on demand like that!

We climbed to the top of the village with all of our precious, fresh samples and arrived at the CSB (basic health centre). The CSB was at the top of a steep hill and I found myself questioning the suitability of its location – you’d have to be pretty fit to be in with a shot of receiving medical attention!

We were welcomed by a lovely young girl who was a newly qualified nurse from a city in the East.  She was in charge of the CSB and also kindly offered to host us for three days.

We spent the day performing our various tests and preparing samples for microscopy, finishing just in time for a dinner served on the floor of the nurses hut; boiled chicken, rice and green leaves with tiny shrimps from the river that you just ate whole.

It suddenly dawned on me why these ‘green leaves’ that we were so eating so often never had a specific name.  I’m pretty convinced that the locals just go and pick some random green leaves from outside and boil them in water as a way to make rice more exciting.

It was a special evening and one that I hope never to forget. The boys and I were pretty content with sitting back and quietly observing the interactions between our two Malagasy team members, the guide from Durrell and the nurse. It suddenly felt like such an overwhelming privilege to be in this situation and in this company, something that one could never experience as a tourist. I will really miss hearing Malagasy being spoken between friends when I return to the UK.

The next day we walked to Betampana which was our final village. We planned not to stay there overnight, but just collect all the samples in one morning (now that Vohidamba had shown us it was possible to collect poo after 10 minutes notice of needing it) and deliver our education programme.  This school was calm and well organised. The parents and teachers stood at the back and seemed extremely interested to hear the education programme that our Malagasy team members (Daniel and Anjana) delivered so well.

Walking to Betampana
Walking to Betampana

We made it back for lunch which was delayed as the nurse was busy delivering a baby.  We didn’t mind waiting though as we sang the Vengaboys outside the hut, initiated by Daniel of course.

We processed the samples and it was a phenomenal feeling knowing that we had handled samples for the last time that trip!

A selfie to celebrate finishing the last lot of kato-katz
A selfie to celebrate finishing the last lot of kato-katz

It was time to leave Vohidamba and make the long walk back to Marolambo, through all the villages that we had stayed in along the way.  We assembled a great team of porters and said our goodbyes and thank yous.

Our Durrell guide was given a chicken by a local villager as a thank you which he ended up carrying in his hand for the entire walk home.  It seems like you’re not a true Malagasy until you can handle a chicken with ease.

Durrell guide holding his chicken
Durrell guide holding his chicken

It was a stunning walk but a scorching hot day which I was acutely aware of seeing as though I was in charge of safety. When we finally staggered into Marolambo that afternoon, we’d all had it, though we all seemed to be in good health. We slumped in our chairs as we ate a big rice meal and then felt like we could sleep for a long while.

We had made it back to Marolambo!
We had made it back to Marolambo!


Madex 2016

Dr Stephen Spencer and Manchester medical students James Penney and Cortland Linder hope to return to Madagascar. Having identified the extreme prevalence of Schistosomiasis within the communities, they would examine the morbidity of the disease more fully. Additionally, the team will initiate educational programs and investigate local health beliefs, water contact behaviour and barriers to disease control to help facilitate future management.