Tuesday, October 09, 2012

Some thoughts on the fun side of Madagascar

Since I’ve mostly written you about the bad side – the hopelessness of the development efforts, the excess of poverty and disease, etc – let me take one (last) blog entry to tell you about the good side of Madagascar.
Madagascar is a country that has a ton of really impressive and extremely unique things to see. Most famously and spectacularly, there are thousands of species of plants and animals that are endemic to Madagascar and found nowhere else in the world. Several species of lemurs, chameleons, and baobabs are among the more famous examples. In certain seasons, humpback whales migrate past the coast and can be seen without even getting on a boat, sometimes with their newborn babies (these are best seen from Ile Sainte Marie and Fort Dauphin in the months of July and August).

In the north I had the opportunity (on weekends, since I was working during the week) to visit some of the attractions. I saw the beautiful beaches near Ramena (which are too windy for snorkeling in the summer months but have amazing marine life you can see at other times of the year) and I also saw, much as I wished I didn’t, the overabundance of middle-aged Frenchmen with young Malagasy women on their arms in Diego. I camped at Montagne D’Ambre NP, where bats swooped by my head as I set up my tent and I heard a troop of lemurs walk by a few feet away in the middle of the night, making their distinctive snorting sound. During the day I saw the world’s smallest chameleon, pulled a leech off of my ankle, and admired waterfalls in utter solitude. At Ankarana Reserve I saw the famous karst formations, a weird freak of erosion that has formed a field of thousands of jagged stone peaks. Near Anivorano, there is a sacred lake where the locals sacrifice zebu to the crocodiles in order to have their wishes granted, and if you go there and throw them some steak, the crocs will come right out of the water and have a feast while you snap pictures.

In the far south, you really feel like you are at the end of the world. Fort Dauphin looks like it has been abandoned, despite being the biggest city in the region. Not too far away from there is the very tasteful Nahampoana Reserve, where you can see ring-tailed lemurs and Verreaux’s sifaka (among other species) up close. The sifaka are particularly hilarious – they are cuddly-looking creatures who have a strange defect in proportionality of arm-to-leg length that means that if and when they walk on the ground they “dance,” although to me they looked more like little fencers, and they reminded me of that animated feline zorro. Or if you want you can visit the Berenty Reserve (I do not recommend), which is owned by this crazy old French guy who has tried to bring in lots of non-native species (even things like elephants, luckily vetoed by the government), including a plant that turned out to be poisonous and has resulted in balding lemurs in the reserve. His whole mindset is incredibly irresponsible and the visit is exorbitantly expensive, and yet 99% of people who come to Fort Dauphin fly in, go to Berenty, and fly out again.

You can also go to the southernmost point of the island, Cap Sainte Marie (where there is a national park and lots of turtles), or a close approximation, known as Faux Cap, a very windswept beach where you truly feel like the only person in the world. Along the way there you pass through a very unusual desert landscape, with red earth and oddly-shaped cactus, as well as the unique triangular palm tree (whose trunk is actually triangular), which is found nowhere else in the world.

Out west, you can visit the area around Morondava, famous for the Avenue des Baobabs, a road lined with huge baobab trees, each over 1000 years old. An impressive sight and popular at sunset. Belo-sur-Mer, reachable only by pirogue or 4x4 (dry season only due to river crossings) is a gorgeous, unspoiled little seaside town where you could easily disappear for weeks to unwind. Near here you find sand dunes in a national park with a lake full of flamingoes. North of Morondava is the Kirindy Reserve, a treasure trove of wildlife (lemurs, a large predatory cat called a fossa, lots of birds and reptiles, and the unique giant jumping rat) and even farther still is the Tsingy de Bemaraha – more of those karst formations, on a bigger scale.

The area around Tana, known as the haute plateau, features a gorgeous landscape of rice fields such that you might at first think you are in Asia. Not too far away is Andasibe NP, where you will find the indri, the world’s largest lemur and one you will never see anywhere but here, as they die when kept in captivity. They have an extraordinarily loud, distinctive cry that you will hear every morning while in the park. The beautiful golden sifaka can also be found here, as well as the leaf-tailed gecko, an amazing creature that is almost impossible to see even when someone is pointing right at it to tell you it’s there.

And that’s just the things that I’ve seen, but there is so much more. On the east of the country is serious rainforest, with more exotic wildlife and remote hiking. Ile Sainte Marie is supposedly an island paradise, and then there are countless other national parks, each of which houses its own unique regional species of flora and fauna, such that no matter how many parks you visit, there are always new species of lemurs and chameleons and everything else to see. And even once you’ve seen those, you still need to come back in a different season, since certain animals are hibernating at different times. Which basically means that you will never run out of things to do and see in Madagascar.

As for how to organize a visit, the country is a serious nightmare to get around independently. It’s not cheap, there is little infrastructure, and in order to see the sights in many places you will need to hire private transport. It is pretty essential to speak at least some French. The food is terrible and if you eat with the locals you’ll never want to look at rice again as long as you live. The Malagasy people are nice enough, but you wont be making friends with the locals very often as you might in other African countries. If I were to come back as a tourist, which I would love to do, I would hire a car and driver (you can’t hire a car without a driver), and I would not come alone, so as to have someone to share the costs and the experience with. 

The other disadvantage of this environment is that it discourages solo travel, and thus when you are in fact a solo traveler it can get very lonely, because there aren’t too many others like you to join up and socialize with. Plus Madagascar is so beautiful that you’ll want to share it with someone. Watching lemurs cavorting in the trees or whales spouting in the water off the coast or the sun setting behind the baobabs, is, I imagine, infinitely better with someone you care about standing next to you. So despite all the negative things I’ve written about this country, I still would recommend a visit (assuming the political situation is relatively stable, which is not a given). The country has a lot to offer, especially for the nature enthusiast, and done in the right way (and with enough cash) could make for an incredibly rewarding and romantic vacation.

Thursday, September 20, 2012

Force feeding African children: the conclusion

A little sheepishly I write you to admit that just after I wrote you my earlier blog post, in which I presented a few options for how we might consider dealing with the aid issue, I found out that these options actually more or less represent the two sides of a long-term and very heated debate between two of the world’s leading economists. No wonder I didn’t have an answer all by myself! However, by the end of my time in Ambovombe, I had also come to a decision as to which side I support, and before I close the book on this subject (for now), I’d like to tell you why I’ve come to believe what I believe. Let’s look back at my options from last time.

Option 1: Force feed the children. As it turns out, this is a mild exaggeration of the argument put forth by Jeffrey Sachs of the Earth Institute (at Columbia, coincidentally). Banerjee, in Poor Economics, dubs this the “supply wallah” argument. Essentially he posits that poor countries remain poor because they are stuck in “poverty traps” (they are landlocked, have lots of disease, don’t have clean water, etc), and without an initial infusion of aid and cash, they can never break the cycle. Additionally, giving them that initial influx of aid will set off a virtuous cycle.

Option 2: Forget it and wait for them to ask us to help. William Easterly, an economist at NYU, is the very vocal proponent of this option, arguing that aid does more harm than good by essentially giving people an easy out, which corrupts local institutions and diminishes creativity and ambition amongst local people who would otherwise be searching for a solution to their problems. Essentially this is the free market – what Banerjee calls the “demand wallah” – argument, in which there is no such thing as a “poverty trap,” and given the right incentive people will always strive to find a way out of their predicament.

Many books have been written by experts on these topics, and if they are still fighting it out amongst themselves, I certainly don’t expect to convince anyone here. But nonetheless, before I even knew who Sachs and Easterly were, I had already settled on option 1. Here are some of my reasons:

1)  In the world of children’s health and malnutrition, certain barriers to advancement really are a trap. There are tons of studies that show increases in educational achievement, IQ points, and lifetime earning potential that are independently linked to small interventions such as giving iodine supplements to pregnant women or deworming treatments to children. If you consider that these micro- and macro-nutrient deficiencies are essentially causing a form of brain damage (as evidenced by the significant functional improvements seen after targeted interventions, or by studies such as one done in Ecuador that showed a decrease of 10-15 IQ points in children of iodine deficient mothers), then it is reasonable to assume that as long as that biological disadvantage continues, it is going to be that much harder for those people to pull themselves out of the cycle of poverty or even to be able to see that they need to.

2)    Aid is not universal, it doesn’t reach every tiny little corner of every country, so if option 2 really worked, we’d be seeing more little pockets of progress where people got fed up by their situation and tried to improve it. We are not seeing very much of that. Mostly people just keep on going the way they always have.

          3) If we don’t choose option 1, then we have a double standard. We consider that in our own countries a woman should not be allowed to starve her child, education and vaccination are mandatory for children, and not providing basic health care is considered neglect. If we believe we have a moral imperative to protect American or European children from neglect, even if it means forcing the mothers to do something they don’t want to do, why do we think it’s ok to let African children suffer from the same kind of neglect?

Furthermore, as Banerjee points out, we take for granted that a lot of these decisions are made for us in the rich world. Our water is piped into our houses already cleaned and disinfected, and our waste is pumped back out again and disposed of properly rather than polluting our waterways (most of the time). We don’t even give a second thought to the fact that the government is “forcing” this on us, because we all know and accept it’s for our own good. But a poor person in the developing world has to go out and buy chlorine if he wants to sterilize his water, and each time he gets a bucket of water, he has to actively put the chlorine in it. Does it really make sense for us to wait for him to realize that he’ll be better off with clean water and that in the long run the economic benefits of improved health will outweigh the costs of the chlorine, or is that really too much to ask of anyone who isn’t an economist or public health specialist? We have already decided it’s too much to ask of our own citizens, so why are people in poor countries any different? Given that the benefits of clean water are well known and indisputable, shouldn’t we help this man? I think so.

I could go on, but I wont. I encourage you to have a read through of some of the books on my list if you are interested in learning more, and even more, to go to one of the countries in the “bottom billion” and experience it for yourself, as there is truly no better way to decide about which side you take in this argument.

Tips for visiting Madagascar’s national parks

In visiting several (but nowhere near even a majority) of Madagascar’s national parks and reserves, I have learned that the guidebooks are woefully inadequate and out of date, there is scant information on the internet, and the staff (including guides and park employees) locally don’t seem very informative either. To that end, in order to help you avoid the mistakes I made and have a more efficient and enjoyable trip, here is a bit of practical information about the parks I visited, which was up to date as of August 2012, although may have changed by the time you get there.

For extremely useful information about several national parks, I refer you to the excellent website of a Czech solo traveler who posted his experience in detail.  I make the following updates to the information on his site (and it goes without saying that the prices for absolutely everything have increased since he wrote his website):

Montagne D’Ambre NP: The trails are no longer sign-posted, so although they are clearly trails, you will have to guess a little which one you are on. As long as you don’t mind wandering a little, you’ll eventually come back out to the road and are unlikely to get lost. The exception is the Mahasarika Trail, which is a tiny little path off to the left of the main path to Amber Mountain summit just before the main path gets completely grown over. If you don’t look carefully for it you will miss it, and it is completely unmarked, but you’ll know it because it is quite steep and goes through the dense forest.

It was absolutely worthwhile to camp in the park (lemurs wandered through my campsite and there were all kinds of animal calls throughout the night). I didn’t see tourists start to show up with their guides till around 8am, so if you start walking at 6am you have a solid 2 hours to see things on your own before you risk getting caught hiking the trails unguided.

Note that the walk from Joffreville to the campsite is quite a steep uphill, and walking in the hot sun with my camping gear it took me about an hour to the park office and another hour to the campsite, although arguably I’m somewhat slower than average.

Reserve de l’Ankarana: Depending on your interests, one day here may well be enough. You can do a four hour walk to the petits tsingy and you will see basically what the park has to offer. The Lac Vert walk I’m told is overrated and extremely hot and you are unlikely to see animals, so if you are after lemurs, you might want to skip it. The grotte des chauves-souris does indeed have a lot of bats, but note that you have to descend (and then later ascend) an extremely steep, uneven staircase and then climb around inside the slippery cave in the dark, and you will really only see the shadowy forms of the bats (which incidentally smell really bad). Let’s just say if I had it to do over, I’d skip it. But if I’d never seen a cave or a stalagmite or a bat before, then I guess I would still do it.

There is a campsite in the park that you can drive or walk to, but it doesn’t seem like it affords any advantage over staying at the basic bungalows near the park office (10,000 Ar), where they also serve very generous portions for lunch and dinner at their restaurant.

Andasibe-Mantadia NP: Note that the Mantadia park and access road were very heavily affected by a cyclone and are now essentially inaccessible. It is possible you might be able to walk there (I didn’t try), but I was told all of the paths except the Sacred Falls are closed.

Mitsinjo Reserve is especially worth a visit at night, since it’s the only place you can do a guided walk at night, but do note that all walks in the park have a guide fee that is per person, not per group, and they are not cheap.

Camping is now 10,000 Ar for a spot with a cover and an actual bathroom, or 5,000 Ar for a spot with no cover and drop toilets across the road from the park center, but this latter often has groups of school kids camping in it and can get loud. Note that the restaurant near the park office is no longer operational, so the only places to eat are a couple of local places in town or at the hotels, all of which are a couple of km from the campsites. There is no good place to stock up on provisions even in the town of Andasibe, so consider buying your food and snacks in Tana or Moramanga.


Reserve de Kirindy: This reserve is outside of Morondava and no one in Morondava seems to be able to tell you anything about it. It is a lovely reserve where you will see lots of lemurs, reptiles, birds and even, if you are lucky, the very evil-looking fossa.

People will tell you it is impossible to reach the park with public transport, but they are wrong. There are taxis brousses going every morning in the direction of Belo-sur-Tsiribihina. They leave from the bus station (“estacionnement”), which is just beyond the main market. Cost is 10,000 Ar and it takes about 2 hours to reach the entrance to the road to the park. From here it is a hot but thankfully flat 4-5km walk (took me about an hour) to the visitor center. The path is off to your left when you are standing at the entrance on the main road, and it is clearly visible as the only place where cars could drive.

Note that camping is no longer allowed in the park due to the presence of fossa (predatory wild cats) near the visitor center (I found this out only after lugging my camping gear all the way over there). There are bungalows (upwards of 60,000 Ar) or dormitories (27,000 Ar per bed) but they are frequently booked due to the presence of researchers staying there long term, so it would be wise to call ahead.  They include mosquito nets, bucket showers, and drop toilets. There is an overpriced restaurant at the visitor center so you do not have to be self-sufficient with food (meals are 20,000 Ar for just the main course with side) unless you are on a budget. Do bring lots of water, as it is hot there and the water is expensive.

It’s worthwhile to do a night walk (30,000 Ar for up to 4 people) and a morning walk (20,000 Ar for up to 4 people), and you can often see the fossa wandering around near the visitor center in the afternoon. The giant jumping rats come out at 10 or 11pm, after the lights go out, and for 20,000 Ar one of the guides will wait by their burrows and come running to get you when one pops out. I felt silly about this and didn’t do it, but if you really want to see the giant jumping rats and don’t want to risk getting eaten by a fossa while you wait alone in the dark, this is the way to go.

Getting back to Morondava there is almost always somebody going in a private 4x4 so if you are friendly you will likely get a ride. Most of them stop at the Avenue des Baobabs on their way back, though, so be prepared to wait or to get a taxi brousse from there. Alternatively, walk back out to the main road the same way you came and you can catch a taxi brousse from there.

Kirindy-Mite National Park:  This is a very new national park and is still very much under development. The information available is extremely little, even from the people in the national park office in Belo-sur-Mer. First of all, to get to Belo-sur-Mer you have to either rent a 4x4 from Morondava (3-4 hours, at least 200k Ar) or rent a pirogue (around 100k Ar, closer to 6-7 hours or a lot more, depending on the wind). In Belo-sur-Mer you can arrange a pirogue to take you to the national park for about 80,000 Ar for the day. Also, if you make a tour for the whole day, no one will think to include lunch, so unless you want to eat your own stale crackers, ask them to cook you lunch (you buy the ingredients and they will cook it on some makeshift coral barbeques without charging you extra). There are two parts to the national park: the marine part and the land part. Park entrance fee is 10,000 Ar per person for the land portion.

Marine: This consists of the famous islands everyone tells you about off of Belo. Be aware that if you just ask a guide and piroguier to take you to the islands and you say you want to snorkel, they will not necessarily take you to where you can see any fish. I would suggest talking to the folks at the NGO Blue Ventures to ask exactly where you should go for good snorkeling, and have them discuss it with your piroguier so that you go to the right place. The water right around the islands themselves is rough, there are jellyfish (annoying and mildly painful but, I’m told, not dangerous), and you wont see any fish or coral there.

Land: This part involves climbing up steep sand dunes, and if you include it as part of a one day tour with the islands, you’ll climb up to the top of one dune where there is a nice view out over a huge lake dotted with flamingos, and that’s it. What no one will tell you in advance, however, is if you have the time (at least an hour and a half), you can walk down to the edge of the lake and actually hike around it. Furthermore, you are allowed to camp there if you want, but they wont tell you this because they think foreigners can’t handle camping without amenities, and there are none there (no toilets, no sheltered campsites). But if you have a tent and don’t mind wild camping, it is allowed. Of note, they are currently developing this park for tourism and by the time you get there, there may well be toilets and sheltered camp sites.

Andohahela National Park: To be clear I didn’t actually visit this park. It is currently closed due to increasing violent attacks by zebu-stealing bandits (the dahalo) in the area. If you are thinking about going, be sure to ask around first to find out if it’s open. That said, if you get a taxi brousse heading west towards Ambovombe, you will pass the park office for Tsimelahy about 2 hours in (clearly visible from the road). But I’m told it’s a long, hot walk from there to the actual park, so be prepared. 

Thursday, August 30, 2012

My Summer Reading List

For those who have been following along this summer, if you are interested in learning more about development, aid, public health in the developing world, problems in the poor countries of the world more generally, and how it all impacts us, here is a list of the (relevant) books I read during my time in Madagascar, as well as the ones that are next on my reading list.

·         The Bottom Billion: Why the Poorest Countries Are Failing and What Can Be Done About It, by Paul Collier
o    A brilliant economist’s thoughts on why the 60 countries that are home to about a billion of the poorest people on earth are not actually developing but stagnant, and should be approached as such, rather than lumping the world into two categories (developed vs. developing).

·         Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty, by Abhijit Banerjee and Esther Duflo
o   Chock full of interesting studies and very well-written book on the various reasons that the poor stay poor, specifically looking at the cultural mindsets that we as first-world citizens may not even think could exist, and how we can help break the cycle.

·         Half the Sky: Turning Oppression Into Opportunity for Women Worldwide, by Nicholas Kristof and Sheryl WuDunn
o   An incredibly moving book written by two Pullitzer-winning NY Times journalists about the myriad ways that women are being oppressed and abused throughout the world and some of the heroic efforts currently underway to fight the problem. Lots of detailed stories of individual women in many countries, and some concrete suggestions for how to get involved.

·         Nudge: Improving Decisions About Health, Wealth, and Happiness, by Richard Thaler and Cass Sunstein
o   This book isn’t about the developing world but it applies equally anywhere. For me it helped to solidify my thoughts about public health interventions, as it gives some insight into how people make decisions and shows you that we don’t always make the best decisions for ourselves. If you are in a position – government, health care worker, even just a voter – to influence people to make better decisions for their own good and that of others (such as quitting smoking or getting vaccinated, for example), this is an interesting read.

·         The Science of Evil: On Empathy and the Origins of Cruelty, by Simon Baron-Cohen
o   A very interesting look at the biological origins of empathy, examining the range from the overly empathic psychotherapist to the autistic person (lacking in empathy but with potentially positive consequences) to the psychopath (lacking in empathy and with negative consequences). I hadn’t intended this book to be relevant to my time in Madagascar, but it helped give me some perspective to think about maternal instincts and how mothers could be willing to let their children starve to death even when they have another option.

·         Code of the Street: Decency, Violence, and the Moral Life of the Inner City, by Elijah Anderson
o   I happened on this book a bit randomly. It is a sociological study by a UPenn professor who spent a lot of time interviewing poor, inner-city blacks in Philadelphia about their beliefs and practices. It is an interesting look into the culture of the inner city, and somewhat surprisingly I found a lot of parallels between what Anderson describes and the culture in sub-Saharan Africa.

·         The Madagascar I Love, by Arkady Fiedler
o   Again a random find (free for Kindle on Amazon). An account by a European explorer to Madagascar in the early 20th century. Amusingly racist, and funny to think how today’s sex tourism industry in Madagascar may have its origins in the custom of providing a girl to every European visitor as a show of hospitality. Interesting to put things into some historical context if you are visiting Madagascar.

What I’ll be reading next:

·         The End of Poverty: Economic Possibilities for Our Time, by Jeffrey Sachs
o   This is Sachs’ seminal work, laying out his side of the aid argument, which is in favor of giving people as much aid as possible in an effort to break the cycle of poverty.

·         The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good, by William Easterly
o   Easterly’s seminal work, in which he (essentially) opposes Sachs by arguing that we must use the free market to encourage development among the poor, as aid will not be useful until people demand it of their own volition.     

·         Pathologies of Power: Health, Human Rights, and the New War on the Poor, by Paul Farmer
o   A look at human rights abuses in the context of public health, with examples from countries such as Haiti, Peru and Russia. Farmer is a passionate physician who is the incredibly inspiring founder of Partners in Health. See also Mountains Beyond Mountains by Tracy Kidder.

·         The Poor and Their Money, by Stuart Rutherford
o   A look at why microfinance does or does not work, by examining how the poor save and budget, which is not at all using the same strategies as the rest of us.

·         Not for Sale, by David Batstone
o   A call to arms against human trafficking

Saturday, August 18, 2012

Being schizophrenic is no fun anywhere, but…

Normally I try not to write so often because I’m afraid you all will stop reading, but I got inspired this morning and wanted to share with you. I’m hoping you’ll decide this is interesting rather than filing me as spam.

Today I went on an exploratory visit to some tiny villages near Ambovombe, looking for sites where my NGO can start doing screenings. Our first stop was Mahavelo, which is about a mile from Ambovombe. What I wasn’t told before going there is that it’s not actually a village in the traditional sense, but a treatment center for the insane.  The story as it was told to me was that in 1992 a Malagasy pastor from the Lutheran Church came here and built the church, around which, as word got out, a town slowly built up composed of “crazy people” and their families.

In fact, however, these people aren’t really “crazy” but possessed by devils, anywhere from one to hundreds, who speak through them, often in tongues. Sometimes the devils bring translators with them, so you will hear the devil speak first and then the translation in Malagasy. Treatment lasts from three months – if there is only one devil inside – to much longer if you have to expel hundreds of them (and their translators). The treatment consists of an intense period of prayer, starting at 4am on Monday and continuing all day every day throughout the week. On Saturday afternoons at 2:30, they all get dressed up in white outfits, burn traditional medicines, and make gestures as though they are slapping the spirits (although apparently they don’t make physical contact) and yell at them to “get out in the name of Jesus Christ.”
The woman pictured here was a “new arrival,” who had just come in today and apparently was likely to run away. As you can see, they have bound her hands and ankles, and I found her lying in the dirt talking to herself, which was, of course, proof that she really was possessed by devils.  To be fair, she was the only one I saw tied up. Most everyone else was working – pounding corn and such – or lying around on mats.

According to several relatively well-educated people here locally, this is all 100% true, both the possession by devils and the efficacy of the treatment. Apparently there are psychiatrists here in Ambovombe, but I was told that only people who “don’t go to church” see the psychiatrists, and those who go to church just go to get their demons exorcised in Mahavelo.

So it looks like there is a niche to be filled by a psychiatric NGO if anyone is inspired, and yet another reason to be thankful for what we have, because as bad as it sometimes is in America, it could be worse.

Thursday, August 16, 2012

Should we be force feeding African children?

I haven’t been very inspired to write for the past month or so, as there has been a lot of drama and negativity amongst the volunteers here that I don’t really want to go into. I had a couple of really nice visits to some national parks, saw dancing lemurs and the world’s smallest chameleon, and now I’m in Ambovombe, an incredibly poor town in the far south of Madagascar.  I had to get here by way of Fort Dauphin, which I expected to be relatively large given that it’s got the only airport in the region, but instead I found a ghost town with what looked like long-abandoned buildings. Given the general deterioration of the situation here in Madagascar, partly because that’s the way it always is and partly because of the “transitional government” (the DJ president who gained power via coup d’etat 3 years ago), there has also been increasing violence in the region. Just last week a band of thieves attacked and murdered people outside of Ambovombe in order to steal their zebu (cows), and it’s not safe to walk outside the main streets during the day or anywhere after dark, which unfortunately starts at 6pm.

But even more striking is the poverty I’ve found in Ambovombe. The region is dry and windswept, the landscape covered in cactus. The town itself is the capital of the region, with about 40,000 people living in it, although it mainly comprises one long, dusty street with some smaller streets off to the side. The big problem here, which has been a problem for decades, is that there is no water. They have dug some wells but they have to go incredibly deep to find water and they keep drying up. They cart in water from these wells via zebu-drawn cart, and people have to buy it, and it’s expensive. As a result of this there has been widespread famine, and various well-known NGOs (you can guess who they are) have been here at various times or continuously through the last several decades trying to help. As one long-term volunteer put it to me, “I think the best answer for the food and water problems here is for everyone to just move somewhere else.”

One large NGO is handing out PlumpyNut, a nut-based protein and vitamin concoction that is designed for severely malnourished children, and various other groups are giving out rice, cassava and other staple foods. Unfortunately what has happened is that anything given to moms for their malnourished kids – including food and hygiene products like soap – is instead sold on the street to buy cassava for the fathers, with only leftovers going to the kids. Despite being educated that malnutrition leads to disease and death in children, the mothers feel compelled, for reasons I don’t entirely understand, to put the fathers first, even if it means their children suffer. Various explanations have been offered to me by locals, for example that people here are short-sighted and unable to see beyond the right now that their child is currently alive, or that elders are held in esteem while children are considered little more than a nuisance, or even that husbands beat their wives if they are not fed first, but I am having trouble wrapping my head around the fact that the maternal instinct does not outweigh all of those cultural factors. And in truth, though I have come here to try to figure out how the NGO I’m working with can contribute to the fight against malnutrition, it is difficult for me to see how I can convince mothers to care about their own children’s welfare if they don’t do so already.

The solution I’ve arrived at is something akin to “directly observed therapy” like we use for TB patients, wherein we would give the kids PlumpyNut but they would have to eat it in front of us rather than take it home where it could be sold instead. Maybe a few better-nourished kids would be enough eventually to break the cycle and show people it doesn’t have to be this way. However, this solution is extremely labor intensive, and moreover it starkly emphasizes the fact that we are forcing something on these people that they do not want. Even if the thing we are forcing is nutrition for children, it starts to walk a line where you begin to question who has the right to tell other people what to do, and why I, as a white person, think I have the right to tell an African mother how to raise her children.

I just finished reading The Bottom Billion, by Paul Collier, a book you should read if you haven’t already. Madagascar is solidly among those bottom billion, which are a group of about 60 countries that, while you may think of them as part of the “developing world,” in reality are not developing at all, but for various reasons are just stagnant. The author tells a story about how the former president of Madagascar, unhappy at having lost an election, decided to blockade a port that was the main source of growth and jobs for his country, in hopes of blackmailing his way back into the presidency. After 8 months and the loss of more than 250,000 jobs, he finally gave up, but by then the foreign companies who had been using the port had been scared off. Collier quotes one company’s manager as saying “If it’s like that, then count us out. We’ll stick to Asia.”

This president’s short-sightedness and selfishness are pretty typical of what I’m seeing here on a day to day basis. These people seem determined to work against their own best interests no matter how hard anyone tries to show them another way is possible. At some point you start to wonder if it would be better to go to a country where they are interested in learning, collaborating and bettering themselves, and to come back to Madagascar when they’ve developed enough to want that, too. One of the major arguments made in The Bottom Billion is that aid to these countries is most effective when timed with movements within a country, such as just after a major conflict, when the people are looking to make changes and improvements. But of course, it’s not so easy to turn your back on a country with such obvious need while you are waiting for them to revolt.

So what’s the answer? Do we force feed the kids and hope that eventually they see the positive effects of good nutrition and want to continue it on their own? Do we throw in the towel and go somewhere where our efforts are appreciated and welcomed in hopes that with cooperation from local people we can make a bigger difference? Do we keep on walking the middle ground, making ourselves feel better by handing out PlumpyNut to malnourished children and ignoring the fact that it’s not actually reaching the children at all? I don’t feel right about the last option, although this is what the major NGOs are doing and it certainly avoids any moral dilemmas about forcing our views onto unwilling people. Of the first two, I don’t know that there is a “right” answer, but I look forward to hearing your comments and opinions.

Sunday, June 24, 2012

The Bat Cave, or… why going to medical school ruins all your fun

The past two weekends I've gotten out of my little town to go do some of the “touristy” stuff in the region. So I could tell you about the beautiful walk I had along deserted tropical beaches last weekend or about the karst formations stretching as far as the eye can see in the Reserve de l’Ankarana this weekend, or about the lemurs I FINALLY saw jumping around in the trees, but I wont. I could also tell you about my project here, but that’s for a separate opportunity (mainly so non-medical people don’t have to slog through it). Instead, I’m going to tell you why my weekend felt like I was in a Michael Crichton novel.

So yesterday, as I am walking through the forest with the obligatory guide, Rosia, at the Ankarana Reserve, she offhandedly tells me that one of her fellow guides died last week. I say something I think appropriately sympathetic, after which she says “yeah, he was 29 and was completely healthy and then all of a sudden on Monday he felt sick, and by Thursday he was bleeding out of every orifice and died.” Oh, I say. Anyone else affected? He was the only one… doctor said it was “gastrointestinal hemorrhage.” Ok. I’m pretty sure Ebola and Marburg viruses have never been reported in Madagascar, so I’m thinking through the differential in my head, telling myself a perforated ulcer or something of that sort is much more likely, and I mostly manage to put it out of my head. We spend about 5 hours together walking through the forest, and we agree to meet again this morning at 7:30.

I show up at the appointed time and Rosia, who was totally fine yesterday, isn’t there, so someone goes to find her. He comes back and says “Rosia is very ill, she had to be taken to the hospital in [the nearest sizeable town] by ambulance. I’ll find you another guide.” People here don't go to the hospital unless something is very, very wrong, so now I’m starting to panic a little, trying to remember what I learned about the incubation periods of Marburg and Ebola, how close you need to get for transmission, etc, all the while knowing full well that the chances of this being anything other than a coincidence are infinitesimally low. And because I’m rational like that, I go on the planned walk to the Grotte des chauves-souris, or cave of bats, with my new guide, Dolphin (pronounced doll-FAN). We stop at some point on the way to look for lemurs (there were none) and of course I had been ruminating so I pull out my phone to see what my medical encyclopedia can tell me about Ebola virus. And what do I find? The animal reservoir is unknown, but it’s thought very likely that it is… bats.

Ok, but I know I’m being unreasonable so onwards I go. It’s a steep 163 stairs down to the entrance of the cave, and even as we get to about 100 feet away I can hear thousands of bats in there screaming loudly and the odor is almost suffocating. It’s one of those smells you can FEEL in the air, if you know what I mean. And at this point of course I go back in my head to all the fungal infections that people get by going into bat caves and inhaling the air and I start to wonder if those are truly found only in the southwestern United States, or if that is just the example they teach us in medical school because that’s where we live and practice.

And then there is rabies, for which bats are one of the most common carriers, which I think about constantly as the bats swoop around my head in the darkness, outlined by the light from my headlamp. Or, more mundanely, the risk of slipping on one of the wet rocks in the dark and breaking a bone, with no way out but to crawl up all of those 163 irregular stone steps on hands and knees. I tell myself to take deep breaths and try to relax, but the idea of deep breaths just makes me think of inhaling all those infectious particles that I know are hanging about in that thick, heavy air.

In the end, through sheer pride or stubbornness or whatever, I follow Dolphin into the depths of that cave in absolute darkness and don’t leave until he has said his prayers to the gods of the cave and told me we have seen everything, and a small part of me is proud not to be one of those screaming foreign women he had told me about who were afraid the bats would get caught in their hair.

Now I’m back in Anivorano, I’ve confirmed that no cases of Ebola or Marburg have ever been reported in Madagascar, and moreover they are usually spread only by contact with secretions. So I’m probably out of the woods. But if not, I’ll let you know in 2 – 21 days.

Monday, June 11, 2012

First impressions of Madagascar

Suffice it to say, life got in the way so I never finished writing about Timor or Australia. Maybe I’ll get around it to it one day, but in the meantime…

Let me start by saying that Madagascar the country, which is a rather large island off the southeastern coast of Africa, is nothing like the movie (which I’ve admittedly seen only the first half of).  There are no lions or penguins or whatever else here. However, since before the island broke off of Gondwana it was connected to both India and Africa but has since been isolated for millennia, it is home to some rather unusual wildlife, including many species of lemurs (found only in Madagascar) and 7 of the world’s 8 species of baobab tree (also see The Little Prince), 6 of which grow only here. It is likewise home to the world’s smallest chameleon and to many other species of wildlife I’ll probably tell you about if and when I see them someday.

What I have seen so far, however, is the people, who are also a bit of an unusual mix, as the highlands of the country were originally populated by Indonesia, while Arab traders mixed heavily with the people in the north, and various other ethnicities are mixed in to make a population that doesn’t really look “African” or “Asian.” In culture as well, having spent time in some of the other former French-African colonies, I guess I was expecting, well, basically an African country with some heavily-accented French speaking. On the contrary, the French spoken here – amongst educated people and those working with foreigners – is actually relatively fluent, and they use the proper “vous” instead of “tu,” which was the mode of address in all in the other African countries I’ve visited. Baguettes are ubiquitous (although horrendous and deserving of the name in appearance only) and in the capital you can’t walk more than 50 feet without seeing a display of some horrifically sugary, icing-covered pastry mimicking the French fashion.  Prices are pretty high and they are obviously used to tourists, at least on the coasts. There was even a tapas bar in the town I just came from – Diego Suarez – though I didn’t try it.

But what’s weird is that despite being #151 on the UN Development Index, which is higher than most other sub-Saharan African countries, Madgascar has the third highest rate in the world of child stunting due to malnutrition, with the current prevalence estimated at 53%, trailing only Afghanistan and Yemen. In the town where I am staying, Anivorano, I have electricity 16 hours per day and no running water. The town is situated along the main north-south road, with a few muddy paths running off of it, and stray dogs, ducks and chickens wandering around everywhere. I have to jump over running streams of trash and god knows what else to get to work in the morning, which fortunately isn’t too far away. And I’m currently fighting an invasion of mini ants, who for some reason have decided they like my water bottle, causing me to do an urgent wipe-off-the-ants jig when they crawled all over me, and now to be very thirsty.

And then there are the little things… like this morning I attempted to get a coffee, which I later learned is only drunk by “old people” here. I went to the woman who sells coffee at the market, and she began by pouring condensed milk – which was thick like raw honey – out of a can. It was full of these huge black lumps, however, and on further investigation it turned out they were bees. They were just flying around and landing in the milk and hanging out there, and she was vaguely picking some of them out and more were landing. Now, I could handle one bee or maybe even two in my coffee – I’ll pick them out, whatever – but upwards of 10 is just too much. That was more bees than milk. I paid the nice lady anyway, and decided three months without coffee isn’t the end of the world.

And then there is this weird thing where they switched over from francs to ariary as their currency several years ago, with the banks last accepting francs as legal tender in 2009, thus none are available now. However, all the prices are still quoted in francs, causing people to have to divide every price by 5 to get to a currency they can pay with, despite most people not having much education at all. This means that they pull out calculators to figure out how much they have to pay, or I presume in their head they visualize that a 1000 ariary note actually says 5000 on it. Maybe they just don’t know their numbers, and assume every number as written is actually times 5 as spoken? Anyway,  I asked the most educated and worldly person I know here about it today and he seemed to think it was totally normal and that francs were still in use, so I asked if I could actually see a franc note. “Of course,” he said, and then explored his pockets to find one, only to eventually conclude that they aren’t around anymore.

Well, I imagine I’ve lost most of you by now, so I’ll end here. I’m here for the next few months working with a medical NGO on the malnutrition problem and trying to set up and run a small clinic, and this time I actually brought my laptop and have a GSM internet modem, so you’ll be hearing from me more often. As always, please keep in touch!

Wednesday, February 29, 2012

Learning a little about forgotten East Timor

Hello, friends. It's been a long time. I'm here in East Timor. I'm going to assume you don't know where that is, since most people don't. It's a little island just to the north of Australia. If it makes you feel any better, this is what I knew about East Timor before deciding to come here: it's a small island in the South Pacific and something bad happened there about 10 years ago. So let me give you the quick and dirty summary of this poor country's history...

The Portuguese came around about 300 years ago during their days of colonizing everything that moved, and they took over this half of the island. The other half is part of Indonesia. In 1975, the Portuguese government had a major overhaul (too long a story for here) and with the support of various people they decided to grant Timor its independence. Well, it didn't take long for Indonesia to decide it wanted Timor for its very own, and they brutally invaded, aided by the superpowers of the world, who wanted to be on Indonesia's good side for the economic advantages. Well, they ruled Timor with an iron fist till 1999, when, prompted by increasing international pressure, the UN supervised a referendum where the Timorese overwhelmingly voted for independence from Indonesia. Now despite the fact that everyone had warned this would happen, and the US and Australia and others not only knew it but sold tons of arms to Indonesia in the meantime, as soon as the results were announced, Indonesia left Timor with the intention of leaving no Timor behind. They set fire to everything, raped, pillaged and killed, until they had truly laid waste to this country. Many, many thousands died. After a few days, an international peacekeeping force was assembled and sent in, but major damage was already done.The country was handed back to the Timorese as an independent nation of East Timor in 2002, but the UN had to come back a few years later and are still here. They are set to leave at the end of 2012, but we'll see if that's a good idea or not.

So now it's ten years later, and although there are signs of the extreme damage that was done here, they have largely rebuilt. Infrastructure is rudimentary at best, with no medical care available to the vast majority of the population, but I'll get to that. There are lots of UN trucks running around everywhere and a fair number of foreign aid workers, all of whom have crazy interesting life stories -- you don't end up in East Timor without doing some pretty cool stuff first. Outside of Dili, the capital, the country is largely undeveloped - basically jungle with a few roads running through it. So far I've found the people quite nice and welcoming, and since there really aren't any tourists here, it's not too spoiled the way other southeast Asian countries can be.

But now to the medical system, which is where I am working. You may be surprised to know that East Timor has the third highest rate of child malnutrition in the entire world. They are also almost at the top of the list for infant and maternal mortality. It's pretty dire, in fact. They have not only an epidemic of tuberculosis, but also of several tropical infectious diseases. Babies are almost all born on dirt floors of rural huts, and traditional medicine holds that you should put dirt on the umbilical cord, not touch the baby till the placenta comes out, and put water on the mother's breasts to help the milk come in. You can see how this might lead to infections. Or consider this - if you get a huge burn from, say, falling into your cooking fire, the way to treat it is to fill it with ashes and bird feathers. So there is a long way to go in this country.

In Dili there is a national hospital, which is staffed mostly by a collection of various foreign doctors, majority Cuban, and a few of Timor's first crop of doctors. They have one CT scanner, which apparently was donated by the Japanese, who specifically did NOT donate any money towards maintenance, so the scanner broke and beds have been brought in to use the CT room as a dengue ward. There is at least an x-ray machine, though, although apparently they only know how to do films from one angle.

I'm working in a little clinic called Bairo Pite, founded by an American doctor with a pretty inspiring story. He has been here for something like two decades and is trying to run his clinic with a model of sustainability - teaching locals to bring skills to their remote villages so that he can reach more than just the folks who turn up in the clinic here in Dili. There are midwives who are semi-autonomous (the first night I was here, there were six births in the clinic), two TB wards, an emergency area, and a lab with basic facilities including a donated PCR machine that can be used to identify drug-resistant TB - pretty fancy for East Timor!

One of the initiatives of the clinic is mobile clinics, where we drive out into the mountains to some extremely remote village and see a bunch of patients. The idea is not just to treat whatever issues they have but to form relationships and start to introduce them to the idea of western medicine. I went out on one, and maybe 30 skinny, scruffy kids came out from every nearby village to see me - not to get medical help, just to check out the "malae" (foreigner).

The patients at our clinic are a huge mix of your basic aches and pains with the most advanced presentations of TB you'll never have read about in your textbooks. There is a dengue epidemic going on here, so in addition to seeing patients in the clinic, I end up making house calls to westerners who are getting sick as well. We have several medical mysteries and some very tragic cases of cancer that we just don't have the facility to treat anywhere in this country so we are left basically with palliation. We've got a selection of psychiatric patients that are a huge challenge as well. So I'm seeing a bit of everything, and I'm given a huge amount of responsibility, which is scary and challenging, but generally very rewarding.

Anyway, that's probably more medical information than most of you wanted, but it's most of what I'm doing here, and I'm working 7 days a week, so I haven't gotten any chance to travel around at all. It's a fascinating country with a history that I think is really important to know because it has important lessons about how powerful countries value the lives of some people over others or value most the oil that they may get from the nearby waters. There are some excellent books written on the history of East Timor by first hand observers, and I'd be happy to share the names with you or tell you more about it if you get in touch with me. That's all for now. Hope you are all enjoying your winter while I battle my heat rash and the mosquitoes down here in Timor-Leste!

Adventure map for 2009...