Located off the South-Eastern coast of sub-Saharan Africa, sits the fourth largest island in the world: Madagascar. It’s a country of just over 25 million people with too many questions and too few answers. With a GDP per capita of just over 450 dollars, a 64 percent literacy rate, and 70 percent poverty rate, we might expect this country to share the same health problems that other poor sub-Saharan countries have. Possibly the largest health issue many of these countries face is the widespread prevalence of HIV/AIDS. Why then, does a country so poor have the same HIV/AIDS prevalence rate as the United Kingdom at 0.3 percent? This analysis seeks out factors that help explain why this is. As it turns out, geographical location, failure to gather thorough statistics, and its poverty all contribute to the low prevalence rate. The latter, most surprisingly, is uniquely true for Madagascar and we will find out why.
First, geographical isolation plays an enormous role in preventing a tidal wave of disease transmission, as Southern African countries have the highest prevalence rates on the planet. South Africa, Mozambique, Tanzania, Swaziland, and Zimbabwe all have prevalence rates from 15-37% of the entire population! There is an abundance of workers that travel for days on end to work in other countries. To an extent, many engage is frivolous behavior while away for work and then come back to their hometowns, only to spread it to others. In Madagascar, virtually no mixing of migrant workers with Malagasy, allows AIDS to remain at bay.
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In addition to its isolation as an island, Madagascar’s low prevalence rate could stem from low urbanization. There is just one city with a population above one million: Antananarivo (Facts About Madagascar, World facts). The population density of the country is 118 people per square mile (Madagascar: Economy, Population...). There are approximately 3200 people per square mile at Holy Cross, for reference. This is relevant because HIV is transmitted most rapidly in highly urbanized, industrial hubs. A high concentration and large movements of people contribute to the spread of diseases. For Malagasy, this is not the case. This is how their impoverished state actually plays to their benefit in terms of diseases spreading. Without highly desired resources or educated people, there is little demand for counties to engage in trade with Madagascar or invest in any sort of manufacturing plant. Many other cheaper options exist for foreign interests that are closer and cheaper. Therefore, work stays local. A large focus of recently-elected president Andry Rajoelina is an attempt to increase productivity among the workforce (AfricaNews). His goal could result in a higher likelihood of transmission of HIV if awareness is not increased. The suspicion that the prevalence rate is already underreported leads to even more concern as to what would happen if workers from surrounding countries became more in contact with Malagasy. Since one of the largest ways in which the disease is spread is through traveling workers, increased exports and economic activity may bring about an epidemic the country is unprepared for. This is especially true if the vast majority of the population is unaware that there is even an issue. There is no consistent internet connection, no newspapers that reach out into the rural areas, resulting in virtually no way for the average family to even learn what AIDS is. The new administration has promised to change that, as we will see later.
To address my second point, statistical analysis of other STDs in Madagascar make us raise a brow, too, as prevalence rates of both gonorrhea and syphilis are among the highest on the planet (Chepkemoi, Joyce, Countries with the highest rates of HIV/AIDS). Sex work is not an unfamiliar profession in Madagascar, and as many as 20 percent of all women have at one point been sex workers (Madagascar Makes Progress Against HIV/AIDS, NBC News). Also on the island, only 12 percent of men engaged in sexual activity have ever used protection (Chepkemoi, Joyce, Countries with the highest rates of HIV/AIDS). It’s quite astonishing that with such negligence we still see HIV/AIDS being kept at bay, or is it? As we will see, there are a plethora of factors that make gathering statistics in Madagascar nearly impossible, making it likely that the prevalence rate we see is only an educated guess — and in fact HIV/AIDS is more common than what’s reported, despite its isolation as an island.
Over 65 percent of Madagascar is rural (Facts about Madagascar, World facts). If an individual living on a farm believes to have contracted an illness, how would they even get to a testing site? According to a recent analysis of Madagascar’s infrastructure conditions, only 5,700 kilometers of the 49,800 kilometers of roads in the country are paved (Facts about Madagascar...). These figures are probably optimistic, the source says, as many of Madagascar's 'paved roads are in terrible shape, filled with potholes and or wide enough for only a single vehicle (How to Explain Madagascar’s Low HIV/AIDS...). Cyclones and other weather conditions often wipe out roads and bridges making travel even more difficult. Even if the Malagasy wanted to get to a hospital for testing, they most likely couldn’t. Most of the sick individuals in rural Madagascar visit the local medic in their town, often to see someone who doesn’t have formal training. Usually, its an individual who relies on knowledge passed down from previous medics to try to help people. Formal testing of any disease requires leaving work, leaving family, and leaving potential income behind to make a several-day journey to a facility. Only thirteen HIV/AIDS hospitals are available on the entire Island (How to Explain Madagascar’s Low HIV/AIDS...). With a country that’s 1,800 miles long and 750 miles wide, finding the time and energy to make a journey like this just is not an option for many people.
Another large issue in Madagascar has attempted to remedy in recent years is increasing education and awareness. The current government is modeling its approach to that taken by South Africa (AfricaNews, “Madagascar President...). As mentioned before, South Africa has faced many issues pertaining to the prevalence of HIV/AIDS, but in recent years, has implemented full-fledged education and prevention awareness programs that have seemed to work well. Their “90, 90, 90” program is one that serves as a benchmark for which struggling countries strive for (Encyclopedia Brittanica). They aim to see 90 percent awareness, 90 percent treatment rates, and 90 percent virally suppressed. Currently, 90 percent of the population living with HIV/AIDS in South Africa have been tested and know they have it. Of that 90 percent, 68 percent are receiving treatment. Of that 68 percent, 87 percent are virally suppressed and are able to return to normal life (Barbière, Cécile. “Madagascar's AIDS Epidemic Rages Undetected...). Programs and setting attainable goals like in South Africa could serve Malagasy well. Looking at the island’s statistics, we see nearly the opposite right now. An astonishing 90 percent of Malagasy have never been tested for HIV/AIDS. Of the 10 percent that has, only two percent are receiving treatment (Barbière, Cécile. “Madagascar's AIDS Epidemic Rages Undetected). A combination of poor education, poor means of transportation, and stigma are three key factors if the government wants to improve their situation.
The stigma of going through the treatment process for HIV/AIDS is one reason why many Malagasy who do have access to testing facilities find themselves not going. A case study interviewing a former prostitute tells us the story of her very personal struggle with trying to educate others and was recently published by NBC News. The setting is on a back street in one of Antananarivo's poorer neighborhoods. A woman named Saholy clutches at the hood of her blue jacket, pulling it down against the light rain. She prepares herself for more verbal abuse from her fellow streetwalkers on the corners. So holy is 39, a single mother of three teenagers, a (former) prostitute ashamed of her life and, for the last couple of years, a weapon in Madagascar's war on AIDS. Several nights a week, she dons a blue uniform and white badge and tries to convince prostitutes to have only protected sex and get regular medical checkups. A quote from Saholy in the article reads, 'the other sex workers insult us and try to drive us away because we are interfering with their work,' said Saholy, who does not want to be identified further for fear her children will learn what she does. 'We leave but keep coming back. Eventually, they will listen to what we have to say” (NBC News) Her work is valuable, but more education is key. Many men pay a lot more if they don't have to use a condom, too. It is difficult for a sex worker who makes little money to resist, she says in the article. And many men believe they can cure themselves of a sexually transmitted disease by passing it on to a prostitute through unprotected sex (NBC News). This insight into the mindset of current sex workers and those who use their services show the initial hesitancy of any willingness to accept change pertaining to their behavior at their jobs. However, stigma cannot be conquered overnight. The work of Saholy using personal experience to try to help others is key for the movement’s eventual success.
Other African countries are making some headway against the disease, too. The number of new infections in Uganda and Kenya has dropped after persistent widespread public campaigns (UNIAIDS.org). But most Malagasy live far from any large city. Despite this, the current administration in Madagascar is taking AIDS awareness seriously, more so than ever in the past. Since Rajoelina took office last year, more than “100 screening centers have been set up”, and mobile testing units are “sent to remote areas” (UNAIDS.org). In addition, old decrepit billboards in Antananarivo have been replaced with educational information about AIDS. The government hopes to “distribute 400,000 HIV test kits by the end of the year” (UNAIDS.org).
Furthermore, in many rural villages, hundreds of local AIDS councils take action in their own ways. The village of Maroambihy, for example, held a carnival sponsored by AIDS awareness, which showed “films and organized home visits reaching more than 8,000 people” (NBC News). Young players in the football club were taught to carry condoms, and women were taught the dangers and risks of a life of sex work. Groups considered “high-risk” get special attention, including young people aged 19 and under who make up half the population of Madagascar. Thousands of teachers are trained in how to convey the AIDS prevention message to their students. Young people can get check-ups at a discount, and training kits are passed out to scout troops so they can talk about AIDS (NBC News).
The response to AIDS starts at the top, as we’ve seen some of the steps president Rajoelina has taken to implement more AIDS tests for the public. Healthcare lately has been a priority in Madagascar and the national AIDS office is actually in the presidential palace (NBC News). A quote from Dr. Fanjaniaina who runs the AIDS office said, 'The AIDS campaign is a personal initiative from the president — he himself negotiates with the donors. The president tells me to go and see out in the country — he wants to see the impact of his policies' (NBC News). Because of his deep care for this issue, this president hopes that more donors will be willing to give money as they are more confident their financial contributions will yield tangible results. Although international contributions have not spiked dramatically in the past few years, the government hopes it has given enough proof of action that the hesitancy for donors is removed.
In conclusion, Madagascar's recent all-out attack on AIDS comes from the fear that HIV will arrive along with a more open economy and an influx of foreign workers. The island has been protected so far largely by its isolation, but it has only to look across the water to Southern Africa to see the killer wave headed its way. Nine of the world's ten most HIV-ridden countries are in southern Africa, with infection rates of more than 37 percent in Botswana and Swaziland (World Atlas). If AIDS takes hold in Madagascar, it could ruin the country completely.
Works Cited:
- AfricaNews. “Madagascar President Andry Rajoelina Sworn into Office.” Africanews, Africanews, 19 Jan. 2019, https://www.africanews.com/2019/01/19/ Madagascar-president-Andry-Rajoelina-sworn-into-office//.
- Barbière, Cécile. “Madagascar's AIDS Epidemic Rages on Undetected.” Www.euractiv.com, EURACTIV.com, 16 June 2016, https://www.euractiv.com/ section/health-consumers/news/Madagascar-aids-epidemic-rages-on- undetected/.
- Chepkemoi, Joyce. “Countries With the Highest Rates of HIV/AIDs.” WorldAtlas, 12 Apr. 2017, https://www.worldatlas.com/articles/countries-with-the-highest- rates-of-HIV-aids.html.
- Facts About Madagascar, http://worldfacts.us/Madagascar.htm.
- “Global Health: Madagascar.” U.S. Agency for International Development, 6 Nov. 2015, https://www.usaid.gov/madagascar/global-health.
- “How to Explain Madagascar's Low HIV/AIDS Rate?” Ärzte Für Madagaskar E.V., https://www.doctorsformadagascar.com/project/madagascars-low-hiv-rate/.
- “Madagascar.” Madagascar Economy: Population, GDP, Inflation, Business, Trade, FDI, Corruption, https://www.heritage.org/index/country/madagascar.
- “Madagascar Makes Progress against HIV/AIDS.” NBCNews.com, NBCUniversal News Group, 17 Dec. 2007, http://www.nbcnews.com/id/22286835/ns/world_news/t/ Madagascar-makes-progress-against-hiv/aids/#.XbRWDi8pCfA.
- Encyclopedia Britannica. “Antananarivo.” Encyclopædia Britannica, Inc., 20 Feb. 2019, https://www.britannica.com/place/Antananarivo.
- Unaids.org. “Newly Elected President of Madagascar Commits to Overcoming the AIDS Epidemic.” UNAIDS, UNAIDS, 17 Apr. 2014, https://www.unaids.org/en/ resources/press centre/feature stories/2014/april/20140417madagascar.
- Why Is Madagascar so Poor?, 12 Aug. 2011, https://www.wildmadagascar.org/ overview/FAQs/why_is_Madagascar_poor.html.
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