Blessings from Marofatsy

imageimageimageimageI 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.


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!


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.


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.

JamesCapture IMG_7181[1]

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 beautiful views 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)

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 

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,