Madagascar cholera epidemic

Position of Médecins Sans Frontières Antananarivo, 22 February 2000 For the first time in the island's recent history, Madagascar has been hit by a cholera epidemic. The first cases were identified in the province of Mahajanga in March 1999. The outbreak spread rapidly there, as well as in the neighboring provinces of Antananarivo and Diégo-Suarez. Due to a lack of knowledge as to how to handle cases and to limited resources, the mortality rate has reached 8% during this first stage of the epidemic. The government of Madagascar immediately requested assistance from the international community, mainly in the form of financing to better control the epidemic. However, direct assistance offered by several non-governmental organizations (NGO) has up to now been refused by the Ministry of Health, which states that Malagasy health care workers are entirely capable of managing the epidemic without the presence of foreign personnel. Since the beginning of the cholera epidemic, the number of cases has continued to increase in the aforementioned provinces, bearing witness to the endemic nature of the disease in Madagascar. Antananarivo was declared to be a focus area of great concern. From Antananarivo, the epidemic spread to reach the district of Morondava in late December 1999. It was foreseeable that the epidemic could reach the southern part of the island during the rainy season, yet this likelihood has continuously been neglected by public health authorities. Officially, the total number of cases has currently surpassed 15,000, and there have been more than 1,000 deaths. In general, local statistics are not reliable, due to the inadequacies of the information collection system. The true figures, including the number of deaths not reported to the public health authorities, are undoubtedly much higher, most likely 30-50%. Currently, the epidemic continues to spread and devastate, especially in Toliara province. Efforts made by Malagasy authorities and their operational partners in the area of prevention (information, education, communication and water, public health, sanitation) are obviously vital, but they are insufficient to launch a comprehensive battle against cholera's devastation. Regretfully, public health structures are currently overwhelmed, as is the general consensus among people in the field, and are no longer able to guarantee adequate treatment. In addition, due to a number of material shortcomings at public health structures, there is a certain reticence to utilize them; in particular, this refers to rural or unstable populations who are precisely the most vulnerable to this outbreak. In order to confront this epidemic, MSF has been mobilizing significant amounts of resources over the past month, in the form of ten tons of supplies and medication, as well as a team made up of a significant number of personnel experienced in fighting cholera, which have arrived in the region and are therefore ready to be deployed. Additional resources could be made available for use within 48 to 72 hours. With these resources, we can contribute to the efforts of the Ministry of Health to reign in the epidemic. We could legitimately do our part to save hundreds of lives. Unfortunately, it is not possible for us to put these resources to use. The Ministry of Health has prohibited us from working within its structures, claiming that it would risk destabilizing general public health policy, replacing and decreasing the authority of Malagasy public health personnel. These challenges are far from unfamiliar to us; thirty years of experience has taught us to take such factors into consideration when we embark on intervention work. Here, as elsewhere, we function based upon the fundamental principle of working within the framework of existing structures and policies, in conjunction and in close cooperation with them. We found ourselves in a situation where we were not allowed to fulfill our obligation of solidarity and assistance to people in extreme need. Despite the critical nature of the situation, our attempts to change the minds of public health authorities and the government have been in vain. Despite admirable efforts made to end the deadlock, the proposed solution cannot fit within the framework of our principles of intervention, especially in terms of identifying priority areas. Therefore, we have no other choice except to say that we have reached an impasse. This said, and despite the urgent appeals from a very large number of people, we unfortunately have no other choice except to withdraw from Toliara province. This withdrawal is immediate and total, and also includes the long-term support programs to public health districts that we have been establishing over the past three years in the southern district of Betioky and in Morondava. How can we continue to work in these areas at the same time as thousands of people have been infected with cholera and many dozens die of it each day, without us being able to intervene? We express the hope that, in the name of populations in danger, an increased awareness of the gravity of the situation will emerge, and public health authorities will adopt a new outlook that will include allowing NGOs to assist in treating victims of this cholera epidemic.