Madagascar is one of the world’s poorest countries, and for locals it’s their poverty that largely determines general health and life chances. For visitors, staying healthy should not be a big issue. You need to be aware of malaria but generally, so long as you take sensible precautions – including taking care of cuts and scrapes and avoiding food that has been left out after cooking – you should have no problems beyond the occasional stomach upset. Beware of the strong sunlight: brightness rather than heat is the damaging element, so wear a hat and use high-factor sun block, especially in your first two weeks. Check that your travel insurance (which is essential for Madagascar) covers medical care, including emergency evacuation, and all the activities you might want to do, including diving. If you’re going to Madagascar for several months, get a thorough dental checkup before leaving home. Be aware that sexually transmitted diseases, including HIV, are rife: using condoms will help to protect you – though abstinence is even more effective.
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For arrivals by air direct from Europe, Madagascar has no required inoculations, though if you’re stopping over in an African country that is within the yellow fever transmission zone (bit.ly/YellowFeverRules), you may well be required to show an International Vaccination Certificate for yellow fever. A yellow fever certificate only becomes valid ten days after you’ve had the jab, but is then valid for life. You should ensure that you’re up to date with your childhood tetanus and polio protection: boosters are necessary every ten years for tetanus and once as an adult for polio. If you’re going to be living for some time in unhygienic conditions, doctors will usually recommend jabs for typhoid, hepatitis A and hepatitis B – although these are not necessary for an ordinary holiday. Depending on the health service provision in your area, or your personal circumstances, some of these jabs may be free, but be prepared to pay.
The whole of Madagascar below about 2000m is a malaria zone, though the parasite (transmitted by the female Anopheles mosquito, which habitually only bites after dark) is much more easily picked up in crowded urban areas and struggles to survive much above 1700m. You need to be most careful when in coastal towns, especially in the northern half of the island, where you should use mosquito repellent on exposed skin in the evening, sleep under a good mosquito net and of course take your malaria tablets diligently.
The commonly recommended preventatives are the antibiotic doxycycline (doxy), taken daily, or atovaquone-with-proguanil, taken daily (sold as Malarone), which, while expensive, has few side effects. These drugs are often available only on prescription, though in some countries you can buy them over the counter. It’s important to maintain a careful routine and keep taking the tablets after your trip. If you’re going to be staying in Madagascar for some time, it’s worth knowing you can buy doxy and other tablets much more cheaply from pharmacies in-country.
Even if you have been taking tablets, if you come down rapidly over the course of a day with severe, flu-like symptoms (aching joints, temperature) you may have caught malaria and should get yourself to a doctor as fast as possible for a blood test and treatment.
Water, food and stomach upsets
While some of Madagascar’s piped water supply is safe to drink, it’s probably safer to rely on the local plastic-bottled Eau Vive, sold absolutely everywhere in 1.5-litre bottles. As for picking up bugs from food, there’s really no evidence that the meals emerging from the hidden kitchens of fine hotels and restaurants are any less likely to give you a stomach upset than street food freshly prepared in front of you. That said, it’s easy to find yourself tucking into street food immediately after handling another bunch of filthy low-value bank notes, so it’s useful to keep a small flask of sanitizer gel to hand.
Happily, the tummies of most short-term visitors, at both ends of the budget spectrum, survive unscathed. Should you go down with diarrhoea, it will probably clear up without treatment within 48 hours. While you’re battling the bug, it’s essential to replace the fluids and salts lost, so drink plenty of water with oral rehydration salts, which most pharmacies carry. If you can’t get these sachets, make your own solution by dissolving half a teaspoon of salt and eight teaspoons of sugar in a litre of water.
Bugs and wildlife
Madagascar’s native fauna is not only beautiful and often unique but largely quite harmless. With the exception of the rarely seen fossa, there are no threatening large animals here, nor dangerous snakes (some snakes are rear-fanged but can’t deliver a dangerous bite to humans unless offered a little finger to chew on). Various invertebrates – scorpions, ants, bees, centipedes, biting flies and the odd spider – can give a painful sting or bite, and you should always be wary of touching hairy caterpillars (or plants for that matter: ask your guide first), but there are no mortally dangerous bugs on the island. While hiking in the national parks, you should be prepared to be occasionally assailed by biting flies, mosquitoes and ticks, and it can be useful to carry mossie spray, liquid or impregnated wipes with you into the forest. In damp, rainforest areas, leeches can be an unpleasant pest, but as their attacks are painless you often don’t realize you have one hanging from your ankle until it’s filled itself with your blood. Use a fingernail to break the seal then flick the leech off.
Health care in Madagascar
Madagascar’s government health system is challenged on all sides, with the treatment of childhood diarrhoea and malaria absorbing much of its limited resources, and occasional outbreaks of cholera (treatable) and bubonic plague (spread by rat fleas) not uncommon – though neither disease is likely to be of any concern to travellers who are not living in squalid conditions in the affected locations. Pharmacies usually have professionally trained staff and are a useful first port of call if you are unwell. Local hospitals and clinics may be able to help, but if you need treatment for serious illness or injury, flying to Réunion (part of the European Union) might be a better plan: it’s what many affluent Malagasy do if they need private treatment.