An all-woman work crew walks down a narrow street.
Women start cleaning up the market in the Anosibe district of Antananarivo.

USAID Helps Stop Plague in Madagascar, but Challenges Remain

How a biodiversity tragedy led to an urban plague outbreak
By Rob Cohen

In November, I took a canoe trip down a rural western Madagascar river expecting to see a lot of lemurs, but instead I saw thousands of hectares of burned-down forest. The problem extends all over Madagascar, even encroaching on national parks.

This story begins, however, two months earlier, when a 31-year-old man, sick with pneumonic plague, took a public taxi ride from Madagascar’s highlands to the capital city of Antananarivo (Tana) and then to the port city of Toamasina, sparking the first urban pneumonic plague outbreak in Madagascar’s history.

The plague count rose slowly in September. A panic started in October.

Many people with possible exposure and a cough overloaded Madagascar’s health system. Rumors spread, and because of the high risk of death from the illness, almost everyone got treated, even if they probably didn’t have plague.

These conditions created a challenging environment for data collection and administering a full treatment course. Madagascar had long treated its seasonal bubonic plague with 44 injections of antibiotics over eight days, despite the availability of a more effective and better tolerated treatment course, and international recommendations to switch. Bubonic plague is the most common type of plague, with swollen lymph nodes where the plague bacteria takes up residence in the body.

Rarely, the bacteria spreads from the lymph nodes into the bloodstream and then the lungs, where it can then be transmitted person-to-person by coughing. That’s what happened this year with the outbreak of pneumonic plague.


A council worker sprays disinfectant in the market in the Anosibe district of Antananarivo, Madagascar, Oct. 10, 2017. Photo: Rijasolo, AFP

USAID is the largest donor to Madagascar’s health system, contributing more resources than all other donors combined. Our relationship with the country’s government and network of programs helped to prevent a bad situation from becoming much worse. In collaboration with the World Health Organization, the Madagascar Government and other partners such as the Red Cross and Doctors Without Borders, USAID played a key role in controlling the outbreak.

Our clinical staff worked with partners and the government to overhaul the treatment protocol with better drugs. Meanwhile, USAID staff and in-country partners urgently set out to strengthen the health system. They helped train hundreds of health care providers on infection prevention and control; trained and mobilized 17,000 community leaders to monitor developments and counter rumors; provided six mobile clinics to transport patients to hospitals within Antananarivo; and donated thousands of masks.

The health workers in turn helped treat more than 2,000 suspected or confirmed cases of plague and identified and treated more than 7,000 people who came into contact with suspected plague patients.

USAID also moved quickly to strengthen the in-country laboratory capacity by quickly acquiring necessary supplies, including two crucial RT-PCR machines and associated reagents.

By the end of November, the outbreak was over.

The root cause of Madagascar’s plague burden is thought to be widespread use of slash-and-burn agriculture.

I worked with local USAID staff and partners to help overhaul the data system in country and expedite the integration of new software into the health system. We discovered that there was a critical delay in transmitting data from paper forms collected in the rural communities during a rapidly accelerating outbreak. The new software would automatically and accurately report data on 28 reportable diseases, including plague.

The Ministry of Health is already working with USAID to implement many of the lessons learned, such as strengthening laboratory infrastructure, ensuring more accurate and timely data reporting, and better communicating the risk of contraction to avoid panic.

But this story goes much deeper than a dangerous disease overwhelming a poor country’s health system.

Madagascar was formerly covered by forests and lemurs. And from 2010 to 2015, the island reported more plague cases than any other country on Earth. Those two facts are more closely linked than I could have ever imagined.


A burned-down forest in western Madagascar. Photo: Rob Cohen, USAID

The root cause of Madagascar’s plague burden is thought to be widespread use of slash-and-burn agriculture. During the rainy season, villagers set fire to existing and regenerating forest zones to clear land for planting, forcing rats to flee these areas and bringing plague into the villages. While slash-and-burn can be sustainable, Madagascar’s practices are the opposite. Villagers do not control the fires, and so they burn down far more forest than is necessary or that can be naturally replenished.

The destruction of Madagascar’s forests is an extreme biodiversity tragedy. The island’s lemurs have been evolving and diversifying into over 100 species for 40 million years, but now they are the most endangered mammals on Earth. A recent census of the ring-tailed lemur found that the population has crashed 99 percent in two decades, from several hundred thousand to 3,000.

Madagascar’s original forest cover has declined by 90 percent due to human activity. Higher river temperatures in deforested areas kill crayfish, crucial to both the river ecosystem and local human protein intake. In addition to this moral tragedy, the potential loss of tourism dollars is immense — tourism contributes around 6 percent of the economy and 206,000 jobs.

USAID and other development partners are urgently working to expand Madagascar’s marine and forested protected areas to preserve biodiversity, but they are racing against the clock. For a country with the world’s 11th-lowest GDP per capita and third-highest stunting prevalence, only a comprehensive development approach can give hope to Madagascar’s people, trees and precious, rare wildlife, including lemurs and fossa.

This was not the end of plague in Madagascar. What started as a canoe trip ridden with thousands of hectares of burned-down forest became the starting point for a solution — one in which USAID is indispensable.

Read more about USAID’s work in Madagascar and global health. Follow @USAIDGH, on Facebook.
Strategic Objective
Urban, Infrastructure, Health, Forestry, Biodiversity

Rob Cohen

Rob Cohen is a public health physician and epidemiologist who serves as USAID’s senior adviser for monitoring and evaluation for maternal and child health.

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