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
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)
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 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
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!
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!
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 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…
Shut the windows to stop hundreds of children watching the strange activities of the vasa (directly translates to ‘white people’)
Light incense sticks and apply Tiger Balm beneath nose
Don protective lab coats and rubber gloves
Set up some music to work by
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
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.
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
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.
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!
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.
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.
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.