I N T E R N A T I O N A L R E P O R T

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Georges Ramalanjaona, MD, DScFrom the Department of EmergencyMedicine, Newark Beth Israel MedicalCenter, Newark, NJ.

Received for publication October 9, 1996. Revision receivedFebruary 6, 1997. Accepted for publication May 15, 1997.

Copyright © 1998 by the AmericanCollege of Emergency Physicians.

Emergency Medicine in Madagascar

The Democratic Republic of Madagascar lies off the southeast-ern coast of Africa and ranks as the fourth largest island in theworld. Average per capita yearly income is about $400 (US). In1990 life expectancies at birth were 52 years for men and 55 yearsfor women. Graduate medical education in Madagascar is mod-eled after the French system.

[Ramalanjaona G: Emergency medicine in Madagascar. AnnEmerg Med June 1998;31:766-768.]

I N T R O D U C T I O N

The Democratic Republic of Madagascar lies off the south-eastern coast of Africa and ranks as the fourth largest islandin the world. It has a surface area of 226,658 square miles,and an estimated population of 15 million. Average percapita yearly income is about $400 (US). In 1990 the lifeexpectancies at birth were 52 years for men and 55 forwomen. Adult literacy is 87.7% for men and 72.9% forwomen, which is among the highest in a developing coun-try. The infant mortality rate reached 120 per 1,000 livebirths in 1990 coupled with a birth rate of 45.7 per 1,000(world average 27.1); half of the population is younger than17.2 The annual population growth is 2.5% with a popula-tion projection of 16,627,000 by the year 2000. The islandhas six provinces, and their capitals serve as the center ofa regional prehospital system. The six major cities have anaverage of 150,000 people except for Antananarivo, theisland capital with more than 800,000 inhabitants.

Madagascar became independent from France in 1960.Health care is provided by physicians, nurses, and midwivestrained in Western methods, traditional healers (MpanaoFanafody) using herbal medicine, and Chinese medicine.3

This is the first article to report the status of emergencymedicine in Madagascar.

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military, city hospital, and private clinics. In contrast, com-munity-based (or rural) ambulances serve only 25- to 50-mile radius. Ambulances offer transport services in 90%of their runs year-round. They are equipped with elemen-tary equipment such as stretcher, oxygen tank, splint, andintravenous solution pole. Each vehicle is staffed by onedriver and one or two locally trained technicians paid byhospitals/private clinics that operate under the supervisionof a medical director. Ambulances also are used for inter-hospital transfer (from rural to regional hospitals) of criti-cally ill patients or multiple trauma victims.

At this time, there is no national certification for EMT/EMS/paramedics or CPR courses for lay people.

E M E R G E N C Y M E D I C I N E

Emergency medicine is an integral part of the Malagasyhealth care system. The scope and pattern of emergencymedicine practice vary according to the type, location, andaffiliation of the hospital involved. In rural and privateclinics, the emergency department is staffed by a nurse, aphysician assistant on-site, and one on-call attending physi-cian who serves as consultant. This team is responsible forscreening, stabilization, and disposition of all patients seenin ED. Critically ill patients or trauma victims are transferredto regional hospitals by ambulance or plane.

At the university hospitals, the ED is housed in separatefacilities under the direction of the chairman of the majorclinical departments in the school of medicine (medicine,surgery, pediatrics, obstetrics/gynecology) because there areno separate emergency medicine departments at the twoschools of medicine. The ED house staff is composed of onespecialty (medicine, surgery, pediatrics) resident who is incharge of any resuscitation, one senior medical student, andone junior student, all under the supervision of an attend-ing physician on call for each specialty. The ED is staffedby one EMT, one or two nurses, and one specialty physi-cian with all the traditional backup specialties. The yearlyED census at the university hospital is about 50,000, andthe admission rate is between 20% and 30%. The distribu-tion of ED patients includes 50% medical, 20% pediatric,10% surgical and trauma, and 20% obstetrics/gynecology.The frequency of medical problems treated in the ED include70% communicable diseases and 30% noncommunicableillness (mainly respiratory). Generally emergency medicineis not thought of as a specialty, and the core curricula ofthe medical schools do not treat emergency medicine as aseparate discipline; an emergency medicine professionalsociety is nonexistent.

M E D I C A L E D U C A T I O N

Graduate medical education in Madagascar is modeled afterthe French system, and the official languages of instructionare French and Malagasy. Knowledge of the English lan-guage is a requirement during postgraduate training. Thereare two schools of medicine under the umbrella of theInstitute of Higher Education. The schools are located inAntananarivo, the capital of Madagascar, and Mahajanga,one of the six provinces. Students enter medical schoolafter completing 12 years of secondary school sanctionedby the earning of the baccalaureate degree. Entrance to medi-cal school is based on grades and letters of recommenda-tion but not on standardized test scores. Tuition is free ofcharge for nationals as well as foreign students, but studentsare required to pay their own expenses for room, board,and books.

The curriculum lasts 7 years. The first 2 years (the “firstcycle” [premedical]) are equivalent to the basic science edu-cation in the United States. The next 4 years consist of clini-cal education during which students must pass courses andclinical rotations in major clinical disciplines. These rota-tions may last from 4 to 12 weeks and are under the super-vision of the individual department chairman or directors.The last year (“Stagiare Interne”) is composed of clinicalrotation in medicine, surgery, pediatrics, and obstetrics/gynecology and is equivalent to the PGY1 (internship) yearin the United States. Doctor of medicine (state diploma)graduation requirements include passing a final clinicalexamination and completion of a doctoral thesis. Togetherthe schools graduate an average of 250 physicians per year.4

On graduation, the license to practice medicine is grantedby the proper jurisdiction. Physicians who have studied witha government grant are required to work in governmentservice for 10 years. Foreigners who have qualified to prac-tice in Madagascar must become naturalized citizens.

P O S T G R A D U A T E E D U C A T I O N

In the last 3 years major clinical departments have startedpostgraduate training in medicine, surgery, and pediatrics.Entrance into these residency programs is competitive andis based on the score on a written test; only six slots areallowed per year per specialty. At this time there are no plansfor an emergency medicine postgraduate training program.

P R E H O S P I T A L S Y S T E M

Antananarivo’s ambulance system covers an average 100-mile radius and has four bases: university (main) hospital,

teaching remains the cornerstone of emergency medicineeducation. Successful introduction of emergency medicinein Madagascar will focus on convincing governmental poli-cymakers and other medical specialties to embrace theconcept of emergency medicine as a distinct specialty.

R E F E R E N C E S1. Pryor FI: The political economy on poverty, equity, and growth of Madagascar, ed 2.Washington DC: World Bank Publication, 1990:15-30.

2. Prospero J, Caliban R: The psychology of colonization, ed 1. Paris: French PublishingCompany, 1984:20-25.

3. Rajaobelina L: Madagascar at a glance, ed 1. Washington DC: Embassy of Madagascar,1983:2-5.

4. Secretariat of the World Health Organization: World directory of medical schools, ed 6.Geneva, Switzerland: World Health Organization, 1988:167-168.

Reprint no. 47/1/90307Reprints not available from author.Address for correspondence:

Georges Ramalanjaona, MD, DSc

Department of Emergency Medicine

Newark Beth Israel Medical Center

201 Lyons Avenue

Newark, NJ 07112

201-926-6853

Fax 201-926-1894

E mail vstdcoord@aol.com

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Emergency medicine student rotation usually lasts 8 to12 weeks and is incorporated in the above major clinicalrotations. Emergency medicine is taught at the bedside dur-ing morning rounds and in formal courses at the university.Students are required to pass both the clinical rotation exam-ination and the didactic part of the emergency medicinerotation.

F U T U R E O F E M E R G E N C Y M E D I C I N E

The introduction of emergency medicine as a specialty inMadagascar will face challenges because primary care takesprecedence over critical care. The primary care health ap-proach is emphasized throughout the training of medicalstudent residents and by the policy of the Ministry of Health.Furthermore, scarcity of resources is a limiting factor inestablishing emergency medicine as a legitimate specialtybecause it requires upgrading of basic infrastructures andadequate training of emergency medicine personnel. Al-though emergency medicine care is relatively inexpensive(paid for by government and major insurance), the imple-mentation will be costly.2 Lack of trained emergency medi-cine faculty and a professional society to teach and repre-sent the interest of emergency medicine among othertraditional specialties are other limiting factors, as is inade-quate public education as to the importance of emergencymedicine in Madagascar.

Consequently there are several approaches in implement-ing emergency medicine on the island:

• Start a visiting student emergency medicine rotationfor Malagasy students/residents in the United States or otherWestern countries to sensitize and train them in emergencymedicine.

• Train more competent faculty to teach emergencymedicine to medical students/residents by establishing anexchange faculty program between Western countries andMadagascar.

• Educate the public and policymakers as to the impor-tance of emergency medicine, and establish a national schooland certification system for EMT/paramedics.

• Integrate emergency medicine as a separate disciplinein the core curriculum of both medical schools.

S U M M A R Y

Clinical care is the main activity of emergency medicine inMadagascar. Academic emergency medicine as a separatespecialty within the two medical schools is virtually non-existent; emergency medicine curriculum is taught as partof the other major clinical disciplines, and formal clinical