A Tale of 13 Tests
By Nancy Palus
In the district health office in Ifanadiana, Madagascar—home to some 183,000 people—sit 13 rapid antibody tests for coronavirus.
“That is gold,” says Laura Cordier, PIVOT’s country director, during a recent video conference she joined from her home in Madagascar. Still, she says, given the complexity of testing for this virus, the PIVOT team and local health authorities are looking at just how the kits fit into their response in Ifanadiana and other rural districts.
The 13 tests—how they got there, how they’ll be used, and the very role of testing—tell a universal and ever-evolving story of combating COVID-19.
Madagascar has 128 confirmed cases, including a small epicenter in the city of Fianarantsoa, about 67 kilometres from Ifanadiana. The Ministry of Health has dispatched rapid tests from a central stockpile to the country’s 22 regions, which in turn sent tests to district health centers.
Ifanadiana District is where PIVOT has worked alongside the Ministry of Health since 2014 to strengthen the public health system to ensure universal access to effective and sustainable health care.
PIVOT had planned to have thousands of tests ready in the country, but procurement hit a number of roadblocks, similar to challenges many countries are facing.
With this novel virus having effectively shut down the world, health experts from Milan to Detroit to Antananarivo grapple with testing, which is so crucial to controlling the spread. Tests are new, tests are few, false negatives abound; the world is far from the systematic testing that’s needed. Meanwhile, many institutions are studying other surveillance methods that would complement testing.
In Ifanadiana, PIVOT and local health workers are taking measures they know will be vital, irrespective of the number of tests at hand—educating communities, monitoring the check-point on the single paved road that bisects the district, boosting access to soap, and preparing at the village level to isolate suspected cases and contract-trace.
Dr. Herinjaka Andriambolamanana—better known by the community as Dr. Njaka—is PIVOT’s manager of infectious disease. He says one of the greatest challenges is getting information to rural communities who have limited or no access to TV or radio, much less internet. In Ifanadiana District, nearly half of the population lives more than a 10-kilometre walk from the nearest health center.
The dissemination of critical information related to COVID-19, then, falls to frontline community health workers. Fety Randrianarivelo, one of the 172 PIVOT-supported health workers in Ifanadiana District, says that it’s already becoming a challenge to manage people’s fears and reassure them that seeking care for any illness is still the best thing to do.
In a way, the people of Madagascar are uniquely armed for this pandemic. Measles and plague are commonplace, and health workers are well-versed in the prevention of infectious disease. And while it’s too early to say how this will affect COVID-19’s impact, only around 3 percent of Madagascar’s population is over 65, compared to nearly a quarter in Italy.
On the other hand, many of the island nation’s people are immunocompromised due to widespread conditions like malnutrition and tuberculosis. And the country has one of the weakest health systems in the world.
If coronavirus came to Ifanadiana, the government would deploy extra personnel and supplies. Still, all that would take time. And even using the tests on hand is not a simple matter, as Laura Cordier points out.
“Because of the waiting period of either sending a test for PCR in Antananarivo or the risk of a false negative with an antibody test, we really have to focus on isolation,” Cordier says. PIVOT is collaborating with local health authorities to create a quarantine area in every commune. “We want to focus on taking no risks and making sure that those cases are completely isolated.” The idea would be to assume a positive and launch contact tracing straightaway.
“Same here.” That was the gist of Boston-based Dr. Lara Hall’s take on the situation in Ifanadiana during a recent virtual panel session that connected her to PIVOT staff on the ground. In a COVID-19-hit world, rural Madagascar and Boston, a US mecca of medicine and science, are linked as never before.
Dr. Hall is former PIVOT medical director in Madagascar and current board member, and now works on the front lines at Cambridge Health Alliance in Boston. “Where I’m practicing is in some ways resource-greater but in other ways resource-limited similar to Madagascar, and we’re struggling with how to use testing,” Hall says.
Each country, each community is finding its way based on its people, resources, and context. What is clear now more than ever is the need for fail-safe, accessible health care based on sound data. While the need is not new—indeed it is the very basis of organizations like PIVOT—the global community is now acutely attuned to its urgency.
As Matt Bonds, PIVOT co-founder and scientific director, says, responding to the COVID-19 pandemic is “just an extreme version of what we do routinely.”
As a leader in data collection and analysis, PIVOT began tracking health system and population health indicators before they began implementing programs. For six years, PIVOT has been using data to understand which aspects of their programs are working and which are not, and adjusting their approach as needed. All of this is to ensure a system that is strong enough to meet the needs of the population it serves, and that can remain resilient in the face of public health crises such as this one.
Thousands of tests, including the 13 at hand in Ifanadiana District, will be part of the data engine for halting coronavirus. So will Fety, Dr. Njaka, and countless others dauntlessly leading the fight. The richness of PIVOT is that its foundation is people, of and in the communities. And that’s Madagascar’s greatest asset in weathering this pandemic.