Friday, August 9, 2013

In Madagascar, a health crisis of people and their ecosystem

A Malagasy farmer tends his field on a misty morning at the edge of the rainforest. Photo by Emory graduate student Morgan Mercer.

By Carol Clark

Madagascar, an island nation off the southeast coast of Africa, is a biodiversity hotspot. Most of its wildlife is found nowhere else on Earth, making the island a top destination for evolutionarily biologists, drawn to the exotic and endangered flora and fauna.

Visitors to a Madagascar rainforest are enthralled by creatures like the comically long-legged sifaka lemurs, jewel-colored chameleons, net-throwing spiders and giant comet moths streaming golden tails.

Meanwhile, much of the local populace is focused on staying fed, sheltered and alive. Houses, food crops and livestock bump up against remaining patches of wilderness. The country is one of the poorest in the world, with an annual per capita income of $400. About 160 children a day die in Madagascar from preventable diseases, according to UNICEF.

“Madagascar is famous for its wildlife, to the point that its people get overshadowed,” says Emily Headrick, a graduate student in Emory’s Nell Hodgson Woodruff School of Nursing. “When people’s children are dying of diarrheal diseases, their priorities are probably not going to include protecting biodiversity.”

"When you go into homes, you see the lack of possessions," says Headrick, above, performing a health assessment. Photo by Carol Clark.

Headrick is part of an infectious disease team, including Emory students from nursing, the Rollins School of Public Health, the Department of Environmental Studies and the Masters of Development Practice program, conducting research in Madagascar. The team, in the country for most of the summer, is gathering baseline data on the health of people, domesticated animals and wildlife in and around the Ranomafana National Park. This “one health” approach may be key to solving some of the complex problems facing the Malagasy people and their unique ecosystem.

“It’s been refreshing for me as a nurse to learn about the environment, and animal health and development policy from the other members of the team,” Headrick says. “No one person’s area of the work is more important than that of the others.”

Photo by Sarah Zohdy.
The project is part of a large-scale effort of conservation and global health being coordinated by Thomas Gillespie, an Emory professor of Environmental Studies and Environmental Health. Gillespie is also director of infectious disease research for the Centre Valbio, an international research consortium at the entrance of Ranomafana founded by Patricia Wright. The ultimate goal is to promote human and wildlife health, while also ensuring the sustainability of the ecosystem.

This summer, the students are focusing on six villages and the fields and forests bordering them. For weeks, they have camped out and hiked up and down the steep trails of the region, often slogging through rain and mud, forging on even while occasionally suffering from bouts of the intestinal diseases they are there to investigate.

“One minute you’ll be struggling up a steep path, brushing back vines with thorns that tear at your hands,” says Sarah Zohdy, a post-doctoral FIRST fellow in the Gillespie lab who is leading the team in the field. “But then you’ll round a corner and see a beautiful waterfall. Or you’ll look down at your boots and notice that the mud caking them is sparkling with flecks of gold.”

The field work began in 2011. The work this summer was largely funded by the Jim and Robin Herrnstein Foundation and Emory’s Global Health Institute and Masters of Development Practice program. The data the students are gathering will be used to implement a system of health care services through a new non-profit agency called PIVOT.

Following are brief bios of the 2013 team members, and their perspectives on the project.

The black-and-white ruffed lemur is known for its loud, raucous calls. Photo by charlesjharp via Wikipedia Commons.

Sarah Zohdy is a biologist who began doing research in Ranomafana six years ago, drawn by her fascination with lemurs.

About 65 million years ago, a small, primitive primate made its way to the island, perhaps on a raft of floating vegetation, and diverged into dozens of species of lemurs, which today are found only in Madagascar.

“When I first came here, I thought the whole island would look like a BBC nature special,” Zohdy recalls. Instead she was stunned during the 10-hour drive from the capital of Antananarivo to Ranomafana to see a largely treeless landscape of terraced rice paddies and the occasional smoke from slash-and-burn agriculture. More than 90 percent of the original forest of Madagascar is gone.

“I just wanted to study aging in mouse lemurs,” Zohdy says. “I didn’t go into this wanting to be a conservation biologist, but I realized that was necessary.” Photo by Carol Clark.

Since humans began settling in Madagascar, about 1,500 years ago, much of the wildlife has disappeared, including at least 17 species of lemurs. About 100 lemur species survive, but many are teetering of the brink of extinction due to loss of habitat.

The issue is critical for people as well as animals, Zohdy says. “When you have humans encroaching on wildlife habitat you have huge potential for zoonotic diseases, and the emergence of new diseases.” Pneumonic plague and virulent strains of flu are examples of deadly outbreaks that have occurred in Madagascar in recent years.

Part of the work of the infectious disease team involves gathering fecal samples of lemurs, people and their livestock. These samples, along with mosquitos and ticks the team is collecting, will be sent back to Atlanta for analysis of pathogens they may contain. “To really understand human health, animal health and environmental health, you have to study all three at once,” Zohdy says.

The strange, clown-like face of a chameleon. More than half the world's chameleons are unique to Madagascar. Photo by Sarah Zohdy.

Emily Headrick is a nurse who prefers being in the field to hospitals. She’s worked as a health educator for refugees in Atlanta and at a clinic in Uganda.

In Madagascar, she is conducting health assessments of families that are randomly selected from the villages in the study. Few people she has surveyed own shoes or toothbrushes. One family, for example, consists of 13 people living in a 10-by-12-foot mud-brick home with a thatched roof, a dirt floor and little else.

Headrick treats a wound. Photo by C. Rist.
In addition to asking questions about the health history of family members, Headrick’s role is to measure and record people’s height and weight and other vital signs and to test their blood for malaria. Most people have never been to a dentist and some report debilitating tooth pain.

“I worked really hard to prepare myself for the fact that we are here to do research, and not to provide health care,” Headrick says.

Determined to do what she can, however, she bought drugs to treat anyone who tests positive for malaria. She also put together a comprehensive first-aid kit, and spends much of her free time cleaning and bandaging wounds.

The simple act of touching someone and taking the time to listen to them talk about their pain is part of the role of a nurse, Headrick says. “It has a different kind of therapeutic value. And it helps build trust in people. This is a long-term project.”

Cassidy Rist is a veterinarian who is now enrolled in the masters in public health program at Emory’s Rollins School of Public Health. She also works part-time in the CDC’s One Health Office.

Too many public health programs leave pets and livestock out of the equation, Rist says. “We need more projects like this, where people from different specialties work together and talk to each other." Photo by Carol Clark.

Rist is interviewing people in village households about the animals they own, mainly poultry, pigs and zebu – a hardy, humped-back breed of cattle. In a typical village, ducks, chickens, zebu and pigs wander amid the mud houses, defecating near water sources and on the same paths where people walk barefooted. People often cage their free-roaming chickens and bring them inside the family home to sleep at night.

“Any pathogens these animals have can easily be shared by the whole village,” Rist says.

Some people tell her that their chickens died of malaria. She explains to them that chickens don’t get malaria. She then asks the symptoms of the birds, so that she can give them information about the likely culprit.

Dogs are also in the mix, often scruffy with ribs showing, and rarely vaccinated for rabies. Rist asked if she could treat the badly injured paw of one dog. The villagers told her that it was fady, or taboo, to restrain a dog so she was unable to help the animal.

Kristin Derfus takes a GPS reading after setting up a mosquito trap. Photo by Carol Clark.

Kristin Derfus is a graduate student in the Rollins School of Public Health, focused on Global Environmental Health. She has done DNA extraction and PCR analyses for diarrheal diseases in the Gillespie lab, and also trained in a CDC lab that researches malaria and mosquitoes.

“Studying diseases in a lab or a classroom is a lot different than seeing people affected by them in real life,” Derfus says. “No one should be dying from these diseases. They’re treatable.”

Derfus is collecting ticks and mosquitoes in each of the villages of the Madagascar study, which are being sent to the CDC for analysis. Cumbersome light traps, with lots of working parts, are used to capture the mosquitoes.

“A lot of things go wrong when you’re working in the field. I’ve learned to think creatively,” Derfus says. She was using plastic bags to keep the batteries of the light traps dry, but the bags leaked where the wires connecting them to the trap protruded. Zohdy grabbed a large banana leaf, slit it up the middle and fitted it over the batteries. “The leaves work perfectly, and you don’t even have to carry them around,” Derfus says.

Malagasy entomologist Tovo Mbolatiana Andrianjafy shows villagers how to identify the type of mosquitoes that can spread malaria. Photo by Carol Clark.

She places the traps under the eaves of a home, near a livestock enclosure, in an agricultural field and in the surrounding forest. Each morning, the captured bugs are counted and identified: Only the female Anopheles mosquito can transmit malaria to humans.

Identifying “hot spots,” where malaria-infected mosquitoes are the most abundant, can help in the development of targeted interventions, she explains.

Derfus says she is learning more about the insects by working in the field with Tovo Mbolatiana Andrianjafy, a Malagasy graduate student at the University of Antananarivo. “When I entered school, I wanted to be a medical doctor, but then I started learning about the role of bugs in disease, and I decided to become a medical entomologist,” he says. “Malaria is a big, big problem in Madagascar, even in Tana (the capital).”

Masters of Development Practice students Morgan Mercer, left, and Paul Kennedy in the field with local guide and technician Rakotonjatovo Justin. Photo by Cassidy Rist.

Morgan Mercer is an Emory graduate student in the Master’s in Development Practice (MDP) program. She has a degree in political science and experience working with international non-profits in Washington, D.C. on HIV-AIDS and community health programs.

In Madagascar, she is using GPS technology to survey and map the villages and their agricultural sites, along with Paul Kennedy, another Emory MDP student.

“We are mapping the layout, and including water sources, latrines, livestock enclosures, streams and roads,” Mercer explains. They will then map the GPS coordinates and data gathered by other team members on households, livestock, and surrounding forest, and any pathogens detected through analyses. The result will be a collection of data visualizations that can be viewed individually, or layered atop one another, using free Adobe Reader software, to show the spatial relationships between all the information.

Conservation, health and development specialists need to take the time to understand and work with people's complex views about their environment, Mercer says. "The Malagasy farmers work their land, feed themselves from it, feel tied to it, and ultimately should be the ones who have say over how it is managed."

A woman goes about her daily chores with her toddler strapped to her back. Photo by Carol Clark.

Mercer hopes to return to Madagascar to work on the implementation phase of a health system. “I want to help deliver a tangible benefit to these villages,” she says.

She recalls visiting one home and noticing that among the few personal effects of the family was a single, tiny photograph of just one of their six children. “I have albums full of photos from when I was a baby, documenting my progress as a human being,” Mercer says.

She snapped a picture of the five-year-old in the family, printed it out in town and returned to the village to give it to him. “I’ll never forget the delight in his eyes when he looked at the photo and recognized himself,” Mercer says.

A family gathered in front of their home. Photo by Carol Clark.

Paul Kennedy served in the Peace Corps in Jamaica and earned a degree in nursing before entering Emory’s MDP program. Kennedy read up on the history of Madagascar before arriving. He finds the Malagasy people exceptionally kind, and is fascinated by their culture.

“I get bored watching lemurs after about a minute-and-a-half,” he says. “I appreciate the beauty of the environment, and it’s definitely a key component to this project, but I’m more into the people.”

Like Mercer, he is eager to see the project move into the implementation phase. “It’s important that our data don’t just end up as statistics in a report,” he says.

While Kennedy is not working as a nurse in Madagascar, he wields duct tape like a roll of bandages. A lot of his down time from field work is spent on odd jobs like patching a team member’s leaky rain boot or repairing a village child’s homemade spinning top. Need an extra mosquito trap? He’ll improvise one from available materials. “I like tinkering with things and building things,” he says.

"I'm learning a lot about how to develop research methods in the field," says Caroline Schwaner. Photo by Carol Clark.

Caroline Schwaner is an Emory senior majoring in environmental studies. Her favorite professor is Eloise Carter, a biologist at Emory’s Oxford campus who is well-known for her class field trips to the streams and woods of Georgia. “Dr. Carter’s really inspiring,” Schwaner says, “because she loves what she’s doing even though she’s been doing it for a long time.”

Working in the Gillespie lab piqued Schwaner's interest in the infectious disease side of conservation biology. She also spent a semester gaining experience in PCR analysis at the CDC.

Rainforest frog. Photo by S. Zohdy.
In Madagascar, Schwaner is applying a low-tech method to assess the water quality of streams running through the villages. She uses a net to scoop out invertebrates – insects, worms and snails – both upstream and downstream from villages and agricultural sites.

“Certain bugs are usually found only in cleaner water, and others thrive more in pollution,” Schwaner explains. Caddis fly larvae, for example, are indicators of clean water while beetles tolerate dirtier conditions.

Schwaner is also using rapid detection tests in the field to screen the human fecal samples the team is collecting for adenoviruses and rotavirus, two common causes of diarrhea. Back in Atlanta, as part of her honors thesis, she will do PCR analyses of the fecal samples from humans, lemurs and livestock to test for a broader range of pathogens.

Madagascar is Schwaner’s first experience in the developing world, and she admits to culture shock. “One of the hardest things for me was getting used to using a latrine shared by a whole village,” she says.

The benefits far outweigh that inconvenience, she adds. “One day we saw four species of lemurs, just while we were walking to work.”

Ashlee Espensen with a village midwife. Photo by Carol Clark.

Ashlee Espensen is a senior from the University of Arizona, Tucson, majoring in biological anthropology. She volunteered to work with the infectious disease team, and covered all of her own expenses.

Although Espensen started off assisting with the lemur research in the forest, she also became interested in human health. “What sparked it was encountering a child in a village who looked two years old, but she was actually five,” Espensen says.

The child had been orphaned as a baby, and had been raised on cans of condensed milk.

“That got me thinking about who cares for a child after a mother dies,” Espensen says. She started a research project to interview midwives of the villages to learn more about maternal and child health.

“When you come here and meet the people and spend time in the forest, you understand why this work is so important,” she says.

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