Field Note: Finding Resilience During COVID’s Second Wave

I’ve been wearing a mask now for the last 36 hours straight, and I feel like I’m slowly suffocating. It’s irrational, I know, but I have an increasing urge to rip off my mask as the hours slowly pass. The sensation brings to mind a particular patient I cared for recently. He was a man in his late fifties with severe COVID-19 who had desperately low oxygen saturation levels. He was actually suffocating. It feels uncomfortable writing that, and I’m guessing even more uncomfortable to read, but this is not a time to avoid facing hard truths.

I’m on the plane on my way back from six weeks in Madagascar. Somehow, each time I’ve traveled to Madagascar in the last year, it happens to coincide with a spike in COVID cases, which adds an extra layer of complexity to such trips. In many ways, this trip was like any other that I’ve taken many times in years before. I visited healthcare facilities (some vastly improved and some still in desperate states of disrepair), I saw patients with our team (some easy to diagnose and treat, and others diagnostic puzzles that left me scratching my head and wishing we had more diagnostic capacity), and I had meetings – lots and lots of meetings.

But this trip impacted me more profoundly than other trips had for a long time. Having spent many years living in rural sub-Saharan Africa and working there intermittently, there’s not a lot that surprises me about this work anymore, but during these six weeks I felt like I got a more real sense of what it’s like to live and work in Madagascar than I had gotten previously – even if that just came in short glimpses.

Alishya and Nirina, one of PIVOT’s moto drivers, en route to Fasinstara, a 2-day trip by motorbike from the tarmac road that requires crossing multiple rivers like the one pictured here.

I feel both invigorated by the progress we’ve made (and continue to make) in Ifanadiana District and concerned about the deep fatigue I sensed in many of my teammates. Working in healthcare can be incredibly rewarding. There are few jobs where you can say you’ve actually saved someone’s life as a part of your daily routine. And yet, when challenges mount, it can be physically, emotionally, and psychologically draining in ways that differ from many other jobs. This is especially true when working in a place where just keeping the lights on, having working sinks to wash your hands, and the necessary medications and equipment to save lives can be a constant struggle. Usually, we write about the victories we’ve had – the improved data systems, the new staff hired, the new programs initiated, etc. – but today I want to focus more on some of the challenges, because I want to recognize and fully honor just how challenging the work our dedicated team does day after day really is.

Seeing the challenges our staff and the people we serve face has led me to think more about the role I play in all of this. Sometimes people ask me why I went through the trouble of going to medical school, and doing a double residency, only to be stuck in meetings most of the day. Like most things, the full answer is complicated. But the simple answer is that being able to combine direct patient care and public health allows me to tackle challenges from both ends, and to feel like progress is being made in one area if not in the other. When an individual patient’s diagnosis is not clear or there’s no available treatment, it’s easy to lose hope, but instead, I can switch to developing new programs or working to change policies that will help many more patients. Conversely, when the team and I are struggling to implement a certain clinical program, we can always go back to treating individual patients, and see the direct impact of our work. This gives me professional flexibility – and a psychological break from some of the struggles associated with this work – that many others don’t have.

That brings me back to the patient I mentioned earlier. I won’t use his real name to protect his privacy – let’s call him Rakoto, because I recently heard some colleagues joking that “Rakoto” is such a common name that it’s the Malagasy equivalent of “John.”

Rakoto spent almost a month in the district hospital that PIVOT supports, and most of that month was truly a struggle for his life. One particular Sunday, when I stopped by to check on him, Rakoto’s oxygen saturation read 39% on nine liters of oxygen. For a moment, I stared at the reading in disbelief. Then I switched the monitor to his other fingers, and got similarly low readings. When I moved the monitor to my own finger, wondering if the machine was faulty, I got a reassuring 98% saturation (normal is 95-100%). At this point in the United States, he would have been transferred to the intensive care unit (ICU). However, we don’t have that option in rural Madagascar. The only ICU capacity is in the capital, 11 hours away, and that capacity was very limited.

So, we did the best we could for Rakoto, given the resources available to us: we put him on the highest level of oxygen we could without mechanical ventilation; started IV steroids; changed his positioning to maximize oxygen delivery to his lungs; and provided supportive care to make sure he was as comfortable as possible. Honestly, I didn’t think that was going to be enough. Each morning when I woke up, I wondered if he was still alive, and I stopped in to check on him when I could.

The day before I left Madagascar, I visited the hospital’s COVID ward, and there was another patient in Rakoto’s bed, and my heart sank. I looked carefully at the patients in each of the other beds in the room, and went through the other rooms in the infectious disease ward, but there was no sign of him. I left not knowing if he had finally gotten off oxygen and had been discharged to home, or if he had succumbed to COVID-19 and passed away.

When I landed in the US, I checked with the team and found out Rakoto had in fact been discharged a few days before I departed. I breathed a sigh of relief. Rakoto’s discharge is a testament to human resiliency and the difference that basic hospital care can make in saving people’s lives. It felt good to know about this one small victory, and yet, I still feel unsettled, because the road ahead during the pandemic is so unclear.

When teaching a social medicine course this past January, we used India as an example of how to successfully manage a public health response to COVID-19. And now, just a few months later, the news is covered with images of burning funeral pyres as COVID-19 ravages the country. It’s hard to say what lies in store for Madagascar and our team, and I know many of them are already exhausted. I find comfort in the fact that we truly are a team, and I think we all find inspiration and support from each other.

I desperately hope that PIVOT team members will be able to get the respite they need from this struggle and then be able to forge ahead with all of the great plans we have developed for strengthening the public health infrastructure and ensuring that everyone has access to care. And that we will be able to move forward with implementing our model for achieving universal health coverage with the Government of Madagascar and have an impact that reaches beyond each of our individual victories. Most of all, I hope each member of our team will remain as safe and healthy as possible throughout the pandemic, and has the resiliency to continue pursuing their goals and dreams – both professional and personal – for many years to come.

Alishya and PIVOT Primary Care Supervisor Lalaina join Ministry of Public Health staff outside of their newly-reconstructed health center during a visit to Ambiabe, one of Ifanadiana District’s rural communes.

 



  • Molecular Diagnostics

    Pivot has partnered with the Ministry of Public Health and Centre ValBio to develop the first molecular diagnostics laboratory for COVID-19 outside of the capital city.  We additionally have partnered with the Pasteur Institute of Madagascar on novel analysis of dried blood spots from I-HOPE survey for serological analysis of measles, malaria, schistosomiasis, Hep B, and COVID-19.

     

    Learn more: 

    Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

    Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

  • Eco-Epidemiological Surveillance

    We collate environmental surveillance data (e.g. vector surveillance) with biomarkers from household surveys (e.g. rapid tests and antibody tests from dried blood spots of participants in the I-HOPE household survey) to inform the spatio-temporal dynamics of infectious diseases.

     

    Learn more:

    Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

    Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

  • GIS (geographical)

    We use a participatory approach to map over 20,000 kilometers of footpaths and 100,000 structures. These data have been combined with high resolution data on land cover, a digital elevation model, rainfall data, and geolocated data from the IHOPE cohort (see above). These data are used to determine travel times to health care, measure geographic equity, and study geospatial determinants of disease. Accessibility modeling results are available on an e-health platform developed with R Shiny.

  • IHOPE (household-level longitudinal cohort)

    The Ifanadiana Health Outcomes and Prosperity longitudinal Evaluation (IHOPE) cohort was established in 2014 at the start of Pivot’s work in Ifanadiana District. Modeled after Demographic and Health Surveys, it tracks standard international health, demographic, and socioeconomic indicators. IHOPE has the following combination of characteristics that are novel for localized interventions:

    • True baseline
    • True representative sample
    • Sample from inside and outside of the initial catchment population
    • Collection by third party professionals at the National Institute of Statistics who collect identical data nationally
    • Tracks same individuals over time
    • Includes biomarkers such as dried blood spots used for molecular analyses

     

    Learn more: 

    Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

  • HMIS and Routine M&E

    Health management information systems (HMIS) collect information on health system utilization and care provision at public sector facilities. These data are combined with additional, routine monitoring and evaluation (M&E) data to track over 1000 indicators of health system performance in Ifanadiana District, including rates of treatment and service utilization, quality of care, supply stock-outs, and human resource capacity at every level. These data are accessible via a real-time dashboard.

  • Capacity-Building

    The purpose of Pivot Science is to improve health outcomes over the long-term. Central to this goal is a new capacity building program, which focuses on both increasing research skills among clinicians/implementers, as well as helping researchers better understand and inform clinical priorities. The training includes a series of workshops on understanding clinical priorities, developing research questions, methodology, and dissemination. Trainees include a range of personnel who work within Madagascar’s health sector.

  • COVID-19 and Molecular Diagnostics

    The majority of deaths in Madagascar are due to infectious diseases and most cases go undiagnosed. The COVID-19 pandemic has underscored the need to implement new diagnostic assays in rural health districts. Pivot has partnered with the Ministry of Public Health and Centre ValBio to develop the first molecular diagnostics laboratory for COVID-19 outside of the capital city, which provides both diagnostic capacity as well as a platform for scientific innovation at the intersection of biomedicine and planetary health.

     

    Learn more: 

    Integrating Health Systems and Science to Respond to COVID-19 in a Model District of Madagascar, Rakotonanahary, R.J.L., et al., 2021, Frontiers in Public Health

    Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

  • Eco-Epidemiology & Surveillance

    There have been major advances in the science of infectious disease dynamics. But there is inadequate application of these advances at local scales to inform health interventions. We combine environmental information, spatially granular health system data, and population surveys, with mathematical models to understand and forecast local disease dynamics (such as malaria, measles, schistosomiasis, lymphatic filariasis and diarrheal disease) to improve service delivery. 

     

    Learn more:

    Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

    Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: Insights from Madagascar, Evans, M.V., et al., 2020, Global Health Action

    Towards elimination of lymphatic filariasis in southeastern Madagascar: Successes and challenges for interrupting transmission, Garchitorena, A., et al., 2018, PLOS Neglected Tropical Diseases

  • Operational Research for UHC

    Operational research provides insights into how programs are implemented with an emphasis on quality and fidelity to organizational, national, and international standards. Our operational research priority areas include UHC financing, health care quality, patient satisfaction, and health worker performance. This is a high priority area for growth across clinical and data teams at Pivot. 

     

    Learn more:

    Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

    Rapid response to a measles outbreak in Ifanadiana District, Madagascar, Finnegan, K.E., et al., 2020 medRxiv

    Networks of Care in Rural Madagascar for Achieving Universal Health Coverage in Ifanadiana District, Cordier, L.F., 2020, Health Systems & Reform

    In Madagascar, Use Of Health Care Services Increased When Fees Were Removed: Lessons For Universal Health Coverage, Garchitorena, A., et al., 2017, Health Affairs

  • Geography & Community Health

    We are advancing new methods that combine granular health system data with a massive GIS dataset containing over 100,000 structures and 15,000 miles of footpaths in the district. This is used to identify geographic barriers and improve the design of the health system to reach everyone. To overcome geographic barriers, we have piloted a model of proactive community health for Madagascar, and are evaluating its impact and feasibility.

     

    Learn more:

    Estimating the local spatio‐temporal distribution of malaria from routine health information systems in areas of low health care access and reporting, Hyde, E, et al., 2021, International Journal of Health Geographics

    Improving geographical accessibility modeling for operational use by local health actors, Ihantamalala, F.A, et al., 2020, International Journal of Health Geographics

    Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar, Razafinjato, B., et al., 2020, medRxiv

  • Population-Level Impact Evaluation

    We measure the impact of our work through the analysis of a district-representative longitudinal cohort. Our quasi-experimental design allows for some of the most rigorously evaluated analysis of health systems change on population health in Africa. These analyses show improvements in nearly every major health indicator, including infant mortality, under-five mortality, vaccine coverage, access to and quality of health care services, and health equity.

     

    Learn more:

    District-level health system strengthening for universal health coverage: evidence from a longitudinal cohort study in rural Madagascar, 2014-2018, Garchitorena, A., et al. 2020, BMJ Global Health

    Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar, Garchitorena, A., et al. 2018, BMJ Global Health

    Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study, Ezran, C., et al. 2019, PLOS Medicine

    Baseline Population Health Conditions Ahead of a Health System Strengthening Program in Rural Madagascar, Miller, A., et al. 2017, Global Health Action

  • Data Systems

    PIVOT is fully integrated with Madagascar’s Health Management information System. By combining many kinds of data – outcomes, programmatic, geographic and more – we gain insights to inform our approaches in an ongoing improvement cycle.

  • Quality of Care

    Care is of no use to our patients’ health unless it is high-quality. We focus on bringing the best possible care to all levels of the health system, whether offered at a patient’s doorstep, at health centers, or at the hospital.

  • Supply Chain & Equipment

    Constant collaboration and integration with Madagascar’s national supply chain helps maintain adequate stocks of more than 40 essential medicines and supplies across all levels of care while steadily closing the gaps on stockout rates and saving lives.

  • Finance

    PIVOT is working with the government’s National Health Solidarity Fund to create a transparent system for patients, providers, donors, and government officials, building on success in removing financial barriers to care through patient reimbursements.

  • HR & Recruitment

    Skilled, well trained and compassionate people are the most vital components of any health system. To meet the unusual challenge of a setting where posting may be truly remote, PIVOT teamed up with the Ministry of Public Health to design and implement a joint recruitment and retention strategy.

  • Infrastructure

    A public health system needs dignified and durable spaces – a difficult task in a mountainous rainforest environment. The district’s most remote facilities are a priority, where partnership with local communities and contractors ensure that rehabilitated spaces are maintained over time.

  • Emergency Transport

    74% of the people in Ifanadiana District live more than a 5-kilometer walk to the nearest health center. Our district-wide public ambulance referral system is the only one of its kind in Madagascar, operating 24/7 since 2014 to bring urgent cases in for treatment at no cost to the patient.

  • Patient Accompaniment

    PIVOT accompagnateurs welcome people into a system that may be unfamiliar. They explain the process, assist in navigating the system,address the need for food and lodging when needed, and check on the kids back home. This service, along with the improved availability and quality of care, has helped quadruple the use of outpatient health services in Pivot’s catchment area.

  • Maternal Health

    Our programs successfully address high rates of maternal deaths among the women in Ifanadiana District, who give birth an average of seven times during their reproductive lifetime, with four in every five deliveries occurring at home. In the first two years of fully supported obstetric services, access to family planning, and facility-based deliveries, the maternal mortality rate dropped by 20%.

  • Malnutrition

    More than half of the children under 5 in Madagascar are chronically malnourished. We are piloting a national program in Ifanadiana District that combines screening, treatment, and prevention across all levels of the health system to address this major cause of child mortality.

  • Tuberculosis

    TB is so prevalent in Madagascar that there are an estimated 500 new cases in our district every year, most undetected and untreated. In partnership with the National Tuberculosis Program,  we launched a program to control TB in 2017 to upgrade basic resources and capacity, and to ensure that diagnosis and treatment are available in Ifanadiana District.

  • Child Health

    Children under 5 are those most likely to die from preventable causes like malaria, pneumonia and diarrhea. We implement protocols for the Integrated Management of Childhood Illness to guide health workers in diagnosis and treatment and to assess nutrition and vaccine status in low-resource settings.