The plague in Madagascar is an endemic phenomenon which reached the epidemic stage in 2017. Alexandra Razafindrabe, a doctor in economics and a researcher at the C3EDM (Centre d’économie et d’éthique pour l’environnement et le développement à Madagascar) attempts to understand the socio-economic, cultural, environmental and institutional contexts in which the disease developed, and to analyse the response of the public authorities and their efficiency with regard to these contexts.

How can the plague epidemic outbreak in Madagascar in 2017 be a subject of research for the social sciences?

Alexandra Razafindrabe: When you study a disease, you can approach it from the angle of biological causes, symptoms, remedies, the number of cases… The hard sciences then take centre stage. But we sometimes forget that the evolution of a disease is largely dependent on human behaviours. The Covid-19 crisis perfectly illustrates this, inasmuch as the adoption of preventive behaviours was the first response put forward in the fight against the epidemic.

In my study, I tried to understand the environmental, cultural, institutional and socio-economic factors which fostered the development of the disease. For example, forest fires and deforestation destroy the natural habitats of rats, who then leave the countryside for urban centres. Another observation: people in situations of extreme poverty are so focused on food that they pay no attention to preventive behaviours. Fighting an invisible enemy is not the priority when the problem of hunger, and therefore survival, is immediately present. Everything revolves around the perception of risk. Finally, certain customs may potentially have an impact. For example, the famadihana is a funeral ritual practised in Madagascar, which consists of removing the deceased from their ancestral burial plots and wrapping them in new shrouds, before putting them back in the family vault. Impact or coincidence, the resurgence of the plague often corresponds to the period of the famadihana.

Taking the multiple facets of a territory into account enables us to understand the context in which an epidemic spreads, and the conditions for the success of the awareness-raising campaigns coordinated by the public authorities.

Your analysis concerns the efficiency of awareness-raising amongst the populations. Which methodology did you use to address this issue, and what were your observations?

AR: Our study aimed to measure the effects of awareness-raising in relation to the different environmental, cultural, and socio-economic spheres. It was based on 27 semi-directive interviews with public and private stakeholders who played or could have played a role in the treatment of the epidemic, and on 724 questionnaires submitted to people from plague red zones. Our questions aimed to evaluate not only people’s awareness of the disease and of good practices, but also to measure the impact of this awareness on behaviours. Some examples of the questions: “Do you think that rubbish increases the number of rats in your neighbourhood? What do you do with your rubbish? Do you think that forest fires help to fight against the plague, contribute to the spread of the plague, or have no link with the plague?” The analysis of the questionnaires showed that the population listens to and assimilates the messages transmitted by the public authorities, but that it does not apply them. The role of rubbish and rats was well understood. The same went for the measures to adopt in order to avoid contracting the disease. People could recite by heart the contents of all of the awareness-raising campaigns, but they did not integrate the behavioural norms into their daily lives. In spite of all the efforts to raise awareness, these norms are not being respected.

The disease is not considered to be a priority, or even a danger. A majority of people interviewed put the plague well behind the lack of infrastructure or food in the list of problems ranked in order of importance. In Madagascar, people fear hunger more than the plague. Illustrating the defiance of the population, a number of respondents even thought that the plague was a means used by politicians to divert attention from the real problems of the nation. The population, being relatively unconcerned by the epidemic, is not ready to call its habits or traditions into question to adopt new behavioural norms and act collectively against the disease.

Which concrete directions for improvement does your study allow us to envisage?

AR: The study aimed to measure the effects of awareness-raising actions and to explore new ways of communicating so that the messages would have a real impact on the populations. We can see that the contents of awareness-raising campaigns is not the problem. It is more that the principle of mass campaigns is not efficient enough. The work of field agents, who intervene face to face, has much better results, probably because they guarantee the coherence between theoretical knowledge and what people are really doing.

And yet, changing behaviours has less to do with communication than with education and culture. In the short-term, there are only sanctions or the fear of the gendarmes that can incite people to follow the rules. As for customs, it seems difficult to attack them. On the contrary, it would be preferable to use them as a relay to develop a culture of cleanliness, for example by involving healers or broadcasting messages by way of hiragasy, a popular traditional art form which combines theatre and song. There are also other artists, who are closer to the youth. Incidentally, they took an active part in the recent awareness-raising campaigns. Their audience is such throughout the country that they are in a position to be the drivers of change. They can transmit impactful messages without stepping out of the cultural context, by instiling a zest of renewal. The point is to make people understand that a culture of cleanliness can also belong to the universe of the populations.

These approaches are already being explored. But establishing new behavioural norms amongst the populations necessarily involves education. To treat the problem at the source, there would need to be a constant collaboration between the stakeholders of disease prevention, health and education, whose domains are often compartmentalised and limited by a lack of human resources, means, equipment and funding. It is a vast, sensitive, complex subject, in which the role of research is to provide tools for analysis in order to help with decision-making.

Photo above: @EU-ECHO