Why diagnostics and health workers matter – a story from Madagascar
It’s 7am on a Saturday morning in August 2022 and I’m sat in the Labo Excellence in Ivato, an airport town just outside Madagascar’s capital, Antananarivo. A small child is looking warily at a nurse approaching with a kit of three test tubes and needle. Luckily, she’s an expert and the blood sample is taken almost before the child realises what is happening. She’s pretty devoid of energy anyway, and only cries a little, which is soon mollified by a biscuit…
This visit to a private laboratory is unusual in just about every way. It’s the culmination of 4 months of illness for this 3 year-old child, multiple rounds of failed antibiotics, and is essentially a story of how a lack of access to community-level diagnostics nearly cost this little girl her life.
The little girl – we’ll call her Clara* – is newly enrolled in our sponsorship and social protection programme, which we implement with our local Malagasy partners Ankizy Gasy. We have been supporting her three older siblings for some time now, and Clara is due to start pre-school next month.
But she’s been unwell on and off for some time now. Some days, she has so little energy, she just sleeps all day, and on others, she has diarrhea, a cough and yellow eyes. They’ve been back to the local doctor several times, with support from SSFA and partners. The doctor knows the family can’t afford even the bus to the hospital, let alone expensive laboratory tests to diagnose the issue, and Clara’s mother feels she is already asking too much of local NGOs in terms of support. So, for nearly 4 months, she’s been relying on broad-spectrum antibiotic prescriptions (three in three months) and traditional remedies to ease the symptoms, which the doctor thinks could be the result of yellow fever.
But Clara hasn’t been improving, and in the days prior to us finding ourselves in the Labo Excellence, she’s taken a turn for the worse, with even less energy. It’s clear that we need a new approach, and after discussing with Clara’s mother, we arrange a trip to a private laboratory, to have a wide range of blood tests done and try to understand better the issues Clara is facing. The cost is around 40 pounds –prohibitive to most ordinary Malagasy, and only available to this family with our support.
The tests take minutes to conduct, and we return back to the village to drop Clara and her mother home, promising we will be in touch when the results arrive. We are sat around the table eating lunch at Ankizy Gasy headquarters, when I’m astonished to see an email flash up on my phone – barely 5 hours since leaving the clinic, the results are in! I send them to a doctor friend back in the UK to ask for an initial quick opinion. She messages back immediately advising that Clara is severely anaemic, has likely pneumonia (shown by elevated white blood cell count), E.Coli and a urinary tract infection. Her advice is to get Clara to a hospital quickly.
We abandon lunch and set off in a borrowed car for Clara’s home. Her mother is understandably concerned, as are her siblings, who will now be left alone (the oldest boy is 15) while Clara’s mother accompanies her. We promise to keep an eye on them, and head to the specialist mother and childrens’ hospital in Antananarivo.
Clara is taken into ‘urgences’ straight away. While the doctors were clearly under some strain - with a young baby fighting for its life on oxygen in the same room - they were kind, professional and clearly very competent.
I am immediately dispatched to the pharmacy across the road - one of around 10 trips I’ll end up making over two days - to collect an assortment of equipment, from antiseptic to syringes. Some items are free and some aren’t - but it all has to be fetched. Nothing is already there and ready to go in the ‘urgences’ centre. We show them the private blood tests and the doctors order several more, which I also need to go and pay for. Impressively, the treatment itself at the children’s hospital is free - but the equipment and tests aren’t. So even if somehow you manage to scrape together the bus fare to take your child to the hospital, you may find there’s not a lot they can do, if you can’t even afford a needle for the doctors to take a blood sample, or a basic bandage. In total, the equipment and tests come to around the equivalent of £10 - but there is no chance this mother could have paid this. It’s the same cost as a month’s rent, for comparison.
As I’m running back and forth across the road to the pharmacy, the other thought that runs across my mind is that it’s super tough to be alone with a sick child in hospital. Nothing is provided - no food, no blankets, nothing. So, you see relatives come and go throughout the day with food, changes of clothes, bedding etc. I quickly run to the local market to grab a few essentials for Clara and her mother. This mother has been on her own since her husband’s death and has no family nearby - so it is me supporting her, with a mixture of French, conversational Malagasy (that doesn’t quite stretch to complex medical crises) and reassuring smiles.
By the time Day 1 is done, a chest x-ray had shown that Clara is indeed suffering from acute pneumonia - and a worrying white shadow on the scan raises the spectre of TB. They also want to rule out hepatitis - but this test can only be done at a private lab off-site.
So I dash across the city with the blood sample, just catching the lab as it is closing and persuading the kind doctor to ring through to the hospital with the results, saving me a trip back to get them. It turns out she’s a graduate of one of children’s centres we support and more than happy to help! Meanwhile, Clara is started on IV antibiotics (cue another pharmacy dash) and I head home at 10pm, after fetching her mother a meal, feeling she is in safe hands.
Upon my return the next day, Clara is also lined up for an iron infusion, to address the anaemia. While she is not hugely underweight, she is malnourished due to the lack of adequate nutrients in her diet. Her mother has been struggling to feed her children during the school holidays and one of the consequences is they have been eating only rice for several months. (SSFA and Ankizy Gasy have since stepped into support Clara’s mother with a start-up grant for her own small business, and support from our social protection programme.)
As I’m chatting with Clara’s mother, a doctor approaches to advise there is a spanner in the works. The hospital’s lab has broken - and there is a need of repeat blood work to confirm the anaemia diagnosis. Basically they can’t quite believe what they’re seeing, when Clara is still seemingly up and able to walk, talk etc. They advise that we can use the lab at the other big hospital across town - but first they need the right tube. And they aren’t willing to hand over one of their own precious sample tubes.
So off I set in a taxi across the city and return, successfully clutching the tube. Poor Clara has yet more blood taken (from her neck!) and off I set to proudly deposit the sample at the lab. But it’s a warm day - and by the time I arrive, 15 minutes later, the blood had started coagulating and is basically a solid block. ‘Tsy mety’ said the lab technician - ‘that’s not ok’. So back across town, another sample from a child who by now had cottoned onto what was happening and had to be physically held down. But no matter, off I go again - only to find the same thing has happened. Of course it had, in the absence of any proper way to transport the blood sample. The doctor decided we’d all had enough, and called it a day at that point. Eventually, they manage to get the lab up and running two days later, and confirm that the anaemia was indeed as bad as first thought.
Clara will spend another 4 days in that hospital. It takes that long for the IV antibiotics to start doing their work; a result, the doctor says, of likely over-exposure to many courses of antibiotics in her young life and infections that have gone untreated for too long. The linkages between AMR and access to diagnostics are coming ever more sharply into focus. But I saw it in action that day.
Because of a lack of access to basic diagnostics in the community, antibiotics are prescribed as a catch-all. Doctors are doing their best for families they know often can’t afford expensive tests. But all the while, antibiotic resistant strains of E.Coli and other bacteria are growing in countries like Madagascar. By the time people arrive in hospital or larger health centres for diagnosis, the problems they have are bigger, more complex and more numerous.
This is a story with a positive ending. Clara got the treatment she needed in the nick of time. But the whole episode highlights a crucial point. Diagnostics matter. They can mean the difference between a good and fatal outcome. Without the private blood test we funded for this child, we would never have known just how anaemic she was, just how many infections she had, just how much her young body was being assaulted by a variety of pathogens. Doctors would have taken days longer to diagnosis and then treat her, especially with a broken lab.
When it comes to health, Madagascar is sadly a country that often slips off the radar. A combination of acute poverty – now exacerbated by the impact of the COVID-19 pandemic and the war in Ukraine – and years of health simply not being a priority means that there’s been a lack of investment in the basic tenets of a functioning health system, including laboratory capacity, community testing for a range of diseases and health workers. This is sadly obvious during episodes like the one I’ve just recounted – despite the best efforts of the doctors and nurses in the hospitals.
Since last August, Clara has started pre-school. As a result of this case and several others that came to my attention during my time in Madagascar in 2022, SSFA has invested in the provision of a full-time community health worker with Ankizy Gasy. Clara has sadly since fallen sick again – but this time, intervention and diagnosis was much quicker, thanks to the support of Tiana, the new health worker. This highlights not only the importance of access to testing, but also of having health workers engaged with vulnerable families, and there to support them.
At SSFA, we will continue to work with our partners to facilitate access to healthcare for the communities where we work; but systemic change and investment in the health system, with the ultimate goal of Universal Health Coverage, is the thing that will make a real difference for all the other Claras out there.
*name changed to protect identity