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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.

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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,

Corty

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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.

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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.

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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.

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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!

Corty

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.

Hannah

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.

Steve

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Madex2016

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…!

James