Madagascar 2017. The “Black Death”……..and other stories.
“Surely he will save you from the fowler’s snare and from the deadly pestilence. He will cover you with his feathers, and under his wings you will find refuge; his faithfulness will be your shield and rampart.” Psalm 91:3,4.
As we touch down on the runway on Sunday afternoon, I have a myriad of emotions flooding through my head and my heart. I am so excited to be back, and thankful for the opportunity, but I know my trip is short. I can’t wait to see everyone here, but the thought of saying ‘hello’ and ‘goodbye’ is quick succession makes me sad. There is also the pain of knowing the suffering so many are experiencing with the drought, and now the outbreak of the pneumonic plague……Still, as I descend the steps into the 35 degree heat, see the beautiful smiles, and hear the familiar greetings “salama” (hello) and “tongasoa” (welcome), my heart is filled with a sense of peace, and I know this will be another wonderful adventure.
This year Madagascar has shot to fame in the international press with reports of the “black death”. The plague is no stranger to Madagascar. It is a disease of poverty and lack of sanitation, and Madagascar is the 12th poorest country in the world. Every year there are around 600 reported cases of plague, mostly bubonic plague, and every so often there is an outbreak of pneumonic plague. 90% of annual cases of plague worldwide occur in Madagascar. There is something intriguing or even gruesome and medieval about the “black death”, and it is this that seems to have caught the eye of international journalists and communities.
There were 2119 reported cases of plague since 1st August according to WHO figures. This total includes confirmed pneumonic (365), probable pneumonic (573), suspected pneumonic (680) cases. It also includes 324 cases of bubonic plague. The number of deaths stands at 171, meaning less than 10% mortality. The reason this outbreak is more concerning is because the pneumonic plague is rapidly fatal if not treated, and, unlike the bubonic plague can spread from person to person.
I am not sure what I was expecting as we started our drive from the airport into the center of town – maybe I was expecting less people to be out, or to see people wearing masks. In fact it seemed like business as usual, except for a few bank staff and tourists wearing masks, and some leafelets and posters giving health advice. Antanananrivo was built for a population of 75,000, but is now home to over 2 million. Vibrant and chaotic. Poverty and wealth side by side. Range Rovers sharing the roads with ox carts and men pulling trolleys laiden with produce to sell in the markets. The mode of transport for most is the “taxi-be” or “big taxi – mini vans built for 14, but normally crammed with at least 25-30 people. All together a perfect environment for disease transmission. The government did act swiftly and shut all schools in the capital (they re-opened on 6th November). They enlisted foreign aid to help with screening and treatment centres, and warned against big meetings and travel in crowded buses. There was certainly no evidence of the population taking heed of the latter two instructions!
The plague is caused by the spread of a bacteria called Yersinia pestis. It is spread from rats to human via the Asian brown flea. The bubonic plague causes horrible lesions in the lymph nodes (bubons). It can be deadly, but progresses slowly, so is much easier to treat and cannot be spread from human to human. The pneumonic plague infects the lungs, and is fatal within 24 – 48 hours if not treated. It spreads from human to human by droplets, so coughing/ sneezing. It is highly contagious within a 2 meter zone of the infected person or by handling the dead body. It is treatable with antibiotics if diagnosed early. Anyone exposed can also be successfully treated prophylactically. This fact created panic buying of the two antibiotics, doxycycline & co-trimoxazole. Many self medicted unnecessarily, and stocks sold out which meant that potentially treatment would not be available for real cases.
Every year people here die from the plague, and thousands more die from other diseases such as malaria and Tuberculosis. Why is it that this outbreak of the plague this year has been such a phenomenon? The number reported was the worst in 50 years. The outbreak was in the dry season which is unusual, and the majority of cases were pneumonic, so the worry of uncontrolled spread is justified – but was this really the reason for the international interest? Or is it because “black death” makes a good story which sells newspapers? There is also a more worrying question circulating across Madagascar – was the number of reported cases real, or was it “fake news”as some Malagasy people seem to think? This would be a terrible truth for many reasons, including the fact that many tourists have cancelled their visits here meaning even more economic hardship.
As numbers of reported cases decline, Madagascar returns to normal life, and this episode will soon be forgotten by the international community. However, the people here face two far worse daily plagues: poverty and corruption. Until the leaders of this country tackle these, outbreaks of disease such as the plague will continue to be a regular occurrence on this island.
As we leave Tana and the plague behind and fly to Manditsara, I am struck by the dryness of the parched earth. On the outskirts of Tana, the padi felds are still green. The view of them is like a patch work of different shades of green. As we leave Tana behind, the clours of the quilt below turn to red and brown. The river beds are dry. On our final approach to Mandritsara we fly over the Mangarahara river. Its dry bed is dotted with bright colours – lambas laid out to dry, women and children digging the dry river bed to expose pools of water. This will be their water to drink, cook and wash.
Arriving in Mandritsara is always a joy. Awaiting us on the dusty runway is the usual gathering of inquisitive children, and a small welcoming group from the hospital team, including our team leader Mat Linley, and my friend Vicky Hopley (optometrist). The familiarity is reassuring, but there have been some changes. There has been an exponential rise in “bajaz” or “tuc-tuc” buzzing up and down the bumpy red earthen roads. The lack of rain this season has meant that the roads have remained dry and passable, which has contributed to their increase. The dry weather has also allowed much needed renovation of the main market area. Although the work is nearly finished, the money for the work has run out, so everything has ground to a halt, and there is no knowing when the work will actually be completed. For now, the whole market has decamped to a much smaller area. As a result, stalls and people spill out onto the main road through town. This has made the whole area fairly treacherous: people, cows, carts, bicycles, motorbikes and the odd car & lorry. The combination has caused a sharp increase in accidents. The main road is the only area of Mandritsara which has tar, so anything motorized can get up to a fair speed. So far we have been relatively protected from serious road trauma by the poor quality of roads and lack of tarmac, however this looks set to change as there is actually work in progress to tar sections of the road – there is even talk of grading the road from town to the hospital……we will live in hope, but you never know!!
Two Women, Two Stillbirths
Just after we arrived at the hospital, we sat down for Tuesday lunch with the team. I realized the surgeons were missing, and I was soon to discover why. That morning, two women had arrived at the hospital. One was 20 years old, the other 14. Both had been in labour for several days. Both were unwell and in both cases the babies inside them had died. The 20 year old had been pushing so hard for so long that she had ruptured her womb, and had to have a hysterectomy as a result. The 14 year old had to have a caesarian section to remove the dead baby. She was able to keep her womb, so she will have the chance to conceive again in the future, but she has been left with a vesico vaginal fistula (VVF). This is the common consequence of prolongued labour, and means that the pressure on the tissues of the vagina & bladder is so great for such a long time that a hole develops and causes urine to leak out uncontrollably. VVF is seen commonly in developing countries where access to healthcare is difficult. These women are often rejected by their husbands, and shunned by their families and communities. The hole can be repared by surgery, and Dr Adrien at the Good News Hospital does this life changing surgery, but it is not always successful, and many women around the world do not have access to this procedure.
The news of these two women made me sad – sad because of the traumatic situations they were living through, but also sad because if these women had lived in the UK, both scenarios would probably have been prevented. Most women in Madagascar do not have access to good antenatal care. This is vital to pick up women at risk of problems in pregnancy and labour. Even those that do have antenatal care often do not have the means to access hospital care. The Good News Hospital is the only hospital in a 200km radius which provides caesarian sections. This means that women who experience difficulties in labour often have to walk several days to get to the hospital, by which time it is too late for the baby or sometimes the mother and the baby…….So I pray for these two women who are coming to terms with the loss of their babies, and the trauma they have experienced. I pray that they will hear the Gospel while they are in the hospital, and that they will experience God’s grace in the midst of this terrible situation.
That is all for this piece, but will send the next one soon!
Thanks so much for all your prayers and support!
Please continue to pray for:
- Madagascar – that the plague epidemic would end, and that the country would have good rain. Please pray for good leaders for this country.
- Please pray for the retirement of Dr Adrien, who has been the hospital director for 22 years, and his wife Mme Giselle who has been the headmistress at the Good News School. Please pray for them as they adjust to their new life, and also for the provision of a Malagasy doctor to replace Dr Adrien, and a headmistress to replace Mme Giselle.
- Please pray that the Gospel would continue to be brought to the Tsimihety region even in this time of change and transition.There are 2 million Tsimihety, but only around 40,000 Christians.
- Please pray for God’s protection at this time of change.
- Give thanks for a really successful retreat – the team arrived safely in Mahajunga after a 16 hour bus ride along difficult roads. Gordon and Christine Molyneaux led the retreat, and Gordon taught on the book of Ruth. Mat Linley, the team leader, led sessions on the team & project vision, working in a cross cultural environment, particularly in the context of a guilt & shame culture. The Kids looked at Jesus as their King. The team were (mostly) healthy. Please pray that the physical & spiritual refreshment will given them all the energy and resilience they need, and also that they will all continue to be challenged by the things they have learned.