Since 2007, Health In Harmony and our partner Alam Sehat Lestari (ASRI) have reduced illegal logging (by 89% as of 2017), achieved important health outcomes (such as reducing infant mortality rate), and helped lift families living around Gunung Palung National Park (GPNP) out of poverty. We’ve done this by using radical listening to facilitate community-designed solutions to the integrated problems that people face. Could the same approach work in other parts of the world?
To answer this question, in 2018 we aim to launch operations in other high-value ecosystems where people’s quest for health and well-being drives ecosystem degradation. This is what was occurring in Borneo, where villagers were harvesting and selling trees in order to pay for their health care. And it’s what we see happening all over the world.
Health In Harmony scouting teams have already conducted field assessments in the Philippines and in other parts of Indonesia, in order to determine the best context for us to open new programs. In October, we conducted needs and feasibility assessments in and around Manombo Reserve, located in southeastern Madagascar. I was thrilled to be part of this trip, having been Health In Harmony’s Executive Director for just under 9 months, to see Radical Listening in action, and get a better sense of the type of places our unique way of working may bring real value.
We do extensive background research before entering a country. Some of the main factors we consider before doing an on-the-ground scouting trip are conservation value and the health and well-being barriers people face. We also consider factors such as partnership potential, safety and security, and impact potential.
The distinct ecosystems and extraordinary wildlife of Madagascar have evolved in isolation for 160 million years since its split from the African continent. Approximately 95% of Madagascar’s reptiles, 89% of its plant life, and 92% of its mammals (including more than 100 lemur species) exist nowhere else on Earth. Lemurs and many of Madagascar’s biological wonders are in danger of extinction due to habitat destruction mostly caused by slash-and-burn agriculture, illegal logging, and poaching for bushmeat. Some 90% of the island’s primary rain forest has already been cleared, causing lemurs to be one of the most threatened group of mammals on earth (1).
Manombo Reserve is one of the last coastal rain forests remaining in Madagascar. It is habitat for eight lemur species, including five listed as endangered. This vital rain forest is disappearing rapidly due in part to unsustainable farming and livelihood practices. Conservation experts, including Dr. Patricia Wright – the world’s pre-eminent lemur biologist – fear that Manombo forest and its lemur populations could disappear entirely without a simultaneous focus on human development and conservation (2).
Health and well-being:
Madagascar’s public health context is equally dire. Diseases eradicated elsewhere, such as the plague, kill dozens of Malagasy people every year. In fact, the most severe outbreak of pneumonic plague in recent history happened just this Fall in Madagascar. Humanitarian crises – including acute malnutrition and famine due to food shortages – rarely gain international attention, yet are an ever-present threat. Nearly half of Malagasy children under the age of five are stunted (low height for age), which is an issue of food scarcity, clean water, and sanitation habits. Childhood stunting rates increase to more than 60% in remote areas, such as the ones we visited.
Protecting forests and elevating people out of poverty are enormously challenging feats in Madagascar due to a perfect storm of factors, including the fragility of democracy. The latest coup d’etat – in 2009 – wrought intense economic damage from which the country is still reeling. Approximately 90% percent of the population lives under $2 a day.
We conducted the assessment with several goals in mind. First, we aimed to gain more insight into the political and development context. We also set out to build relationships and trust with the national authorities and other key stakeholders. Most importantly, we wanted to begin radical listening exercises with communities around Manombo Reserve, to understand the people’s challenges and what they thought might be potential solutions.
Led by Kari Malen (International Program Director) and Amy Krzyzek (International Partnerships Manager), HIH conducted radical listening exercises with nine communities bordering Manombo Reserve. The groups that welcomed us ranged in size from 20 to 70 people. In these meetings, we asked them how they could live more in balance with the forests of Manombo Reserve. Dr. Kinari Webb, our Founder, often remarks how quickly the villages around GPNP in Borneo came to consensus about the solutions to their challenges. Incredibly, this was also our experience in Madagascar; each community told us, in their own words, a similar if not identical narrative.
First, food is a critical need. These communities currently do not have enough to eat and their long term food security is looking bleak. Many people are already turning to emergency coping strategies, such as, as well as foraging or hunting for food inside Manombo Reserve. Many people talked about harvesting wild potatoes from the reserve; even though they know they have little nutritional value.
Second, villagers around Manombo Reserve were nearly unanimous in telling us that seasonal hunger gaps (‘lean’ seasons) are exacerbated by the changing weather and destructive natural disasters. They know about – and want – fast-growing varieties of rice, but it would require training to cultivate them and money to buy the expensive seeds. If they’re to ever get ahead of the hunger curve, they recognize the need to learn growing techniques adapted to fluctuating growing seasons.
Lastly, there was a consensus that health care access and quality is insufficient. Transportation to health care facilities is expensive and unreliable. A mother carrying her sick baby can walk hours to a main road for a bus to the nearest clinic, only to find each passing vehicle already full. This means walking to a clinic is sometimes the only option, and that can take hours. With fields to work and mouths to feed, mothers are put in the impossible position of spending money they don’t have to find a doctor for a sick child, at the expense of tending to the needs of the rest of her family – or not going at all.
The lack of willingness to make the journey also stems in part from an uncertainty regarding the quality of care available. Rural doctors and nurses – few and far between because they are irregularly paid by the government – often flee rural clinics for urban centers. Health care itself is ostensibly free, but the cost of inpatient stays, drugs, and corruption make the reality very different. The collateral costs of health care are often more than a family can bear.
For the children in these communities, their malaria, diarrheal diseases, neonatal complications, and acute respiratory infections – the biggest causes of infant mortality – usually go untended until it’s a medical emergency, and then it’s often too late. A lack of access to basic health care in these remote, rural areas means many children never receive routine immunizations, increasing their vulnerability to malnutrition and infection from tetanus, measles, and tuberculosis.
The people we met were impoverished by any standard. Basic needs were unmet at a level I’d only ever witnessed inside conflict zones – in places like the Kivus or Central African Republic. I had the sense in rural Madagascar that natural disasters rob people of life and dignity the way violence does in conflict-prone parts of the world. The threat of drought, cyclones, and flooding – on top of their terrible impoverishment – jeopardizes their survival.
The greatest dilemma assessment teams face is managing expectations. We question people about intimate details of their lives, and – although we do so sensitively – we know that we may never be able to take action. Many of the communities we met had seen numerous organizations come and go. Without getting their hopes up about our return – they were hopeful. One villager told us many organizations had come to his village to ask about their needs and the challenges they face. And then, he added: “But you are the first one that’s ever asked us what we think the solutions are.”
I left Madagascar feeling the immensity of needs people have inside the communities we visited. And ultimately, I felt determined. It’s time for a different approach to the preservation of life on earth, one that regards human well-being and conservation of our natural world as one and the same.
So what comes next? Currently, we are in the process of comparing and contrasting the multiple field sites we have assessed. It is critical to find sites that share certain contextual elements, in order to robustly test and compare the effectiveness of our intervention model across sites.
We are also actively seeking funds from various donors for a multi-year intervention at one of these replication locations – which is, of course, the key enabler – and aim to come to a decision in early 2018.
Thank you for following and supporting our site visits; please stay tuned for more updates. Expanding our program sites to bring forest preservation, poverty reduction, and improved health and well-being to people in other countries will be a challenging journey. My greatest desire is that our entire community of supporters around the world joins us on this journey, and helps spread the word about Health In Harmony’s important work in your own networks.
1. Hannah L, Rakotosamimanana B, Ganzhorn J, Mittermeier R, Olivier S, Iyer L, Rajaobelina S and Hough J, Andrianialisoa F, Bowels I and Tilkin G (1998). Participatory planning, scientific priorities, and landscape conservation in Madagascar; Environmental Conservation 25 (1): 30–36.
2. We send huge gratitude to Dr. Patricia Wright and Maya Moore, Chief Technical Advisor at Centre ValBio (CVB), who were both instrumental in the planning and execution of our assessment. Dr. Wright is a world-renowned primatologist, professor of Anthropology at Stony Brook University and founder of Centre ValBio (CVB), a research station located inside Ranomafana National Park. Dr. Wright was the driving force behind the creation of Ranomafana National Park, a 106,000-acre World Heritage Site in southeastern Madagascar, home to many endangered species, including some 15 species of lemurs. We are grateful for her eagerness to support Health In Harmony.