Preventing Plague: Strengthening health systems in Madagascar

Preventing Plague: Strengthening health systems in Madagascar

The peak epidemic season for plague in Madagascar is fast approaching, but its severity could be significantly reduced with improvements to the country’s public health system, according to a new Viewpoint published in PLOS Neglected Tropical Diseases.

I interviewed lead author Matthew Bonds from Harvard Medical School and the nongovernmental health care organization PIVOT about the challenges and potential solutions for curbing plague outbreaks in Madagascar. Find our discussion below.

What drew you to studying global health?

MB: My formal academic training is in economics and ecology. I am intellectually interested in ways of understanding how health inequity emerges from complex socio-ecological systems. While those notions are fascinating, they also can be pretty theoretical or “academic,” and they raise major moral questions. Earlier in my career, I wanted to understand these issues more directly through firsthand experience, and there is no better mechanism for doing that than to be involved in trying to solve practical problems. I began working with health care providers in Africa and eventually moved to Rwanda about 10 years ago.

Even in the most economically poor communities, there is often a basic vibrancy and dignity that can somehow get lost in our agenda for global health and economic development. Having been fortunate enough to connect with so many extraordinary and wonderful people in many countries reinforces my sense of tragedy when lives are lost unnecessarily. However, this also heightens my sense of opportunity because most causes of death and suffering from disease among the poor are preventable or treatable.

You wrote about two main types of plague in Madagascar, bubonic and pneumonic. What causes these different forms?

MB: There are both biological and socio-economic drivers of plague. Plague is a zoonotic disease caused by a bacterial infection, Yersinia pestis. Though there are multiple hosts of the disease, the most common transmission pathway of the bubonic form in Madagascar is via fleas that feed off of wild rats and then switch to humans at times when rat populations seasonally decline. The pneumonic form occurs when the bacteria colonizes the lungs. Pneumonic plague can be transmitted person-to-person and is generally expected to be fatal within a couple of days of symptoms. The most recent outbreak in Madagascar was due to the pneumonic form reaching an urban center. There are thus socio-economic and demographic factors (such as sanitation, living in proximity to rodents, and urbanization) that influence exposure in the human host, and environmental factors that influence reservoir dynamics and zoonotic transmission.

What do you think are the biggest challenges for prevention and treatment of plague in Madagascar?

MB: We see the biggest problem as a weak health system. While there are many drivers of plague, it is not a coincidence that 2017’s epidemic happened in the country with the lowest-funded health system in the world. Without treatment, plague is typically fatal. But it is almost always curable with inexpensive antibiotics that are produced generically if treated early enough. For patients to access those antibiotics, they need to seek treatment at the onset of symptoms (which are similar to those of malaria or pneumonia).

I work with an organization called PIVOT, which is partnering with the Ministry of Health to create a model health district in a rural area in the southeast of the country. In our district of Ifanadiana, there were over 30 suspected cases of plague and nearly all survived. We had one unfortunate fatality in the case of a woman who did not seek treatment. This is evidence that if the medicines are available, the communities are sensitized, and the health system is staffed and equipped, then people will seek treatment and can be diagnosed and treated effectively even in the poorest and most remote communities. Such treatment not only saves the lives of infected individuals, but also prevents potential human-to-human transmission in the case of pneumonic plague.

What are your proposed solutions for improving Madagascar’s health system to prevent future plague outbreaks?

MB: The treatment of plague is simple to administer but many pieces of the system have to align to work for the patient. We identify three basic components to a strengthened health system: 1) horizontal “readiness,” which ensures adequate infrastructure, staffing, and supplies at all levels of the health system (primary, secondary and tertiary facilities); 2) vertically integrated clinical programs that ensure disease-specific protocols and processes are administered; and 3) data (or information systems).

Each of these components is critical. Citizens need to be able to use and trust the health system, which can only happen if the system works on their behalf for whatever symptoms that arise. Access to drugs, for example, can’t be effective if the staff are not trained and compensated enough to be reliable at the health facility. In Ifanadiana District, the Ministry of Health and PIVOT are partnering to create a model health system at the level of a government district that works. Early evidence is showing that this can nearly eliminate plague-related mortality. This does not prevent transmission from rodents to humans, but can prevent pneumonic outbreaks involving human-to-human transmission.

How can working with the Ministry of Health help Madagascar fight plague?

MB: Treating plague requires the same health system as treating pneumonia or malaria, which claim tens of thousands of lives annually in Madagascar. In Madagascar, the clearest path for coordinating the many components of the health system in order to serve all people — especially the vulnerable — over the long term is through the national health system run by the Ministry of Health. The Ministry of Health has fairly strong policies guided by the World Health Organization but does not have sufficient resources and support to implement these programs adequately. International partners and nongovernmental organizations are positioned to either strengthen or weaken the national system depending on how they engage. As I said in my previous response, the Ministry of Health and PIVOT are partnering to demonstrate how to create a health system at the level of a government district that works for all patients.

What is the next step for curbing plague outbreak in Madagascar?

MB: Last year’s plague epidemic shares many similarities with other global epidemics in recent years. The initial outbreak and rapid spread of disease creates alarm in the international community, which was mobilized to provide a very important emergency response. But the investment in long-term solutions is relatively weak. The concept of “health system strengthening” (HSS) has had some currency in the past decade in the global health community but there continue to be major barriers to financing support for HSS in ways that are rooted in integrated primary care. We emphasize the need for bottom-up, field-based mechanisms to channel resources and align nationally endorsed programs.

Nongovernmental partners are well positioned to both channel international resources and support the national strategy. As one example, we hope to scale the Ministry of Health-PIVOT partnership to more districts in coming years. In addition to this, there are specific opportunities for better surveillance. Data systems at the primary care level (community health workers and health centers) could be better integrated with methods for early warning signals (e.g., through mobile technologies) and the Ministry of Health would benefit from having additional reference labs for diagnosis that operate locally or regionally.

Image Credit: Bonds et al (2017); Matthew Bonds

Reference: Bonds MH, Ouenzar MA, Garchitorena A, Cordier LF, McCarty MG, Rich ML, et al. (2018) Madagascar can build stronger health systems to fight plague and prevent the next epidemic. PLoS Negl Trop Dis 12(1): e0006131.


Tessa is the Journal Media Manager at PLOS. She graduated from the University of California, Berkeley with degrees in Rhetoric and Music. She can be reached by email at and on Twitter at @tessagregs.

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