Series: Roots of an Outbreak

How the Next Pandemic Could Start

Part Two
Madagascar

We’re investigating the cause of viruses spilling over from animals to humans — and what can be done to stop it. Read more in the series →

Part Two
Madagascar

We’re investigating the cause of viruses spilling over from animals to humans — and what can be done to stop it. Read more in the series →

Jocelyn knew only one way to live. Growing up next to the Manombo Special Reserve in southeast Madagascar, his family taught him from a young age to see the forest as a source of income. His grandfather had been a logger, cutting trees for timber and burning wood to make charcoal to sell. His grandfather taught his father, and his father taught him.

It was dangerous work. He risked landing in jail for illegal logging every time he ventured into the protected reserve. “I needed to feed my family,” recalled Jocelyn, who doesn’t use a surname; the vegetables he grew near his house weren’t enough. He also needed money for health care. Once, when his wife was pregnant and fell ill, he sold all of their plates and pans to pay for treatment at a government clinic. She wound up losing the baby anyway.

Then in 2019, Jocelyn went to a meeting that upended his life. Representatives from an American nonprofit, Health In Harmony, asked villagers who lived around the forest: “What do you need from the world as a thank you to continue to protect this precious rainforest that the health of our planet depends on?” The answers across 31 villages were consistent: health care, job alternatives and help growing food for their families.

The following year, representatives from each of those villages gathered in a soccer field to watch as their chiefs pressed inky thumbs onto paper, signing an agreement that affirmed their communities would stop encroaching on the forest. In return, Health In Harmony began providing affordable health care through mobile clinics and teaching residents how to grow more food and support themselves without cutting down more trees.

Founded in 2006 to save rainforests and combat climate change, Health In Harmony may have stumbled upon a way to help prevent the next pandemic.

Researchers have shown that deforestation can drive outbreaks by bringing people closer to wildlife, which can shed dangerous viruses. Scientists found these dynamics can explain several recent outbreaks of Ebola, including the largest one nearly a decade ago in Guinea, which scientists believe started after a toddler played in a tree that was home to a large colony of bats. The child may have touched something contaminated with saliva or waste from an infected bat, then put his hands in his mouth, inadvertently giving the virus a foothold.

The moment in which a virus jumps from an animal to a human is called spillover. Though we now know more than we ever have about why, where and how these events happen, global health authorities have failed to make preventing them a priority. Instead, they’ve focused resources on fighting outbreaks once they begin.

Many see stopping deforestation as an intractable problem that would eat up the scarce money set aside to combat pandemics. Experts convened at the request of the World Health Organization last year argued that the “almost endless list of interventions and safeguards” needed to stop spillover was like trying to “boil the ocean.”

But this Portland, Oregon-based nonprofit, with an annual budget of just $5.3 million for programs in three countries, is demonstrating how working creatively across health, agriculture and the environment may be the key to prevention.

The organization has managed to quantify its success at its pilot location in a rural part of Indonesia on the island of Borneo. With help from Stanford University researchers, Health In Harmony analyzed 10 years of patient records along with satellite images of the forest there, comparing 73 villages that signed its agreement to places that hadn’t. They estimated that the project averted 10.6 square miles of deforestation and achieved significant declines in malaria, tuberculosis, neglected tropical illnesses and chronic obstructive pulmonary diseases, even while the rates for some of these conditions increased in the surrounding region.

In 2019, Health In Harmony launched its program in Madagascar. An island nation off the southeast coast of mainland Africa, Madagascar is a biodiversity hot spot with hundreds of mammals and birds that can be found only there. Researchers say the extensive range of unique animals makes it a more likely place for a novel virus to emerge. Madagascar fruit bats, which roost in the Manombo reserve, can carry coronaviruses, filoviruses (the family of viruses that includes Ebola) and henipaviruses (the family that includes the brain-inflaming Nipah and Hendra viruses). Rats and fleas in parts of the country carry the bubonic plague.

Madagascar was once known as the “green island,” but the lush areas of the Manombo reserve now are filled with holes cleared by loggers or people using trees to make charcoal. On the fringes, slash-and-burn farming has scarred the hillsides, sending red dust and gritty sand over the landscape when the dry-season winds blow.

But today Jocelyn walks in the reserve without his former trepidation. He works for Health In Harmony as a paid “forest guardian,” trekking barefoot through the reserve to collect seedlings and deter loggers, people harvesting wild yams and hunters poaching lemurs. His observations are used to grade the village three times a year. There’s a strong incentive not to break the rules: Fewer infringements earn villagers a deeper discount on testing, prenatal care and other health care services that the nonprofit provides.

“I have learned that the forest, humans and animals are interdependent,” Jocelyn said, “and if the forest is sick, then the animals will be sick, and animals will surely impact humans’ health too.”

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On a clear morning last October, 40 people were already waiting when Health In Harmony’s van pulled into Karimbelo, a coastal village of about 500 residents on the southern edge of the Manombo reserve. Some mothers stood with babies tied to their backs with brightly patterned cloth. An elderly woman, who was recovering from a broken hip, sat in a wheelbarrow that a young man pushed to a makeshift clinic set up by the van.

Before the nonprofit arrived, the only option for health care here was to walk three hours on hilly terrain to a government clinic that few could afford. Some villagers recall neighbors dying on the road on their way to seek care.

Now, two teams, each with a doctor and two midwives, visit 13 sites like this around the reserve on rotation so patients are seen in each location twice a month. Medicines cost substantially less than what they do in a government clinic, but most people choose to pay with an alternate currency: cups that they weave from reeds that grow next to their rice paddies. The cups piled up around the feet of Dr. Néhémie Fiderantsoa Andrianasoloherilana, an energetic 30-year-old who goes by “Dr. Dera”; he traded them for medicines that treat malaria, fevers and coughs.

Health In Harmony uses the cups to hold tree seedlings in its 11 nurseries. Villagers help the nonprofit plant 50,000 trees a year in an effort to reconnect gaps in the forest. The nonprofit’s programs in Madagascar, Indonesia and Brazil follow an approach known as “one health,” which posits that human health is intrinsically connected to the health of animals and the environment, and that to address one requires addressing the others. Dr. Dera has seen how slash-and-burn agriculture can harm people’s lungs and believes that rates of malaria and bubonic plague could be reduced if forests were left untouched.

Though Health In Harmony is based in the U.S., its staff is hired locally. Dr. Andriantiana Tsirimanana, its director in Madagascar, says his upbringing as a child of farmers made him particularly interested in working for the organization. He and his staff have worked to build trust with the local residents. When COVID-19 vaccines became available, conspiracy theories circulated and nobody showed up to get their shots. Tsirimanana rolled up his sleeve in public. Now about 70% of adults in the organization’s treatment area have received the vaccine, compared with 8% for the country as a whole, according to Health In Harmony.

There are limits to what the organization can do. As a primary care provider, it doesn’t pay for hospital visits. The nonprofit plans to seek government approval to treat tuberculosis, but it currently isn’t authorized to help those patients. When two sisters in Health In Harmony’s treatment area tested positive for TB, they had to go to a government clinic for treatment. Though the medicine would have been free, the clinic was a seven-hour walk away, and the women, both single mothers, couldn’t afford the bus fare for weekly visits for the six-month treatment period. They both died last year, leaving their mother to raise six grandchildren.

Still, more villages are eager to join Health In Harmony’s project. Some residents south of the Manombo region have been asking the group to expand, but so far, the team has had to decline. It’s too small to meet the needs of the larger area.

In addition to health care, a big draw is the nonprofit’s support of farmers. Hunger was driving villagers to scavenge and log in the forest. The nonprofit introduced new varieties of crops that allow farmers to grow sweet potatoes in three months rather than nine and to harvest rice two to three times a year rather than once every eight months. Trainers showed communities how to make fertilizer using a mix of dead plants and dung from zebu, a type of cattle. In one village, the organization replaced the leaky wood in an irrigation channel with concrete, a move that helped protect rice paddies during a severe drought last year.

Bruno, king of the village of Morafeno, originally was drawn to the nonprofit’s health care but has come to appreciate the agricultural programs even more as climate change has wreaked havoc. In the past, when there were no crops left to eat, he recalls neighbors foraging for wild yams and honey, often eating plants not meant for human consumption. “Many people died for nothing,” said Bruno, who uses one name.

There have been occasional setbacks. A pilot project to grow cash crops, including cloves and vanilla, was destroyed by a cyclone. While Bruno still worries about the ongoing drought, the farming improvements have convinced him his village will survive. “We are not afraid of hunger anymore,” he said.

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Health In Harmony is now planning a project to measure its ability to restore biodiversity, improve the health of people and wildlife and reduce the risk of spillover in Madagascar. Partnering with Zoo New England, Centre ValBio and researchers at four universities, Health In Harmony plans to document the diversity of regional wildlife; test rodents, bats, tenrecs and lemurs for pathogens; and track human diseases affected by the environment. In all, the researchers estimate a 10-year project will cost $8.9 million — more than 1.5 times the nonprofit’s annual budget across the countries in which it operates.

Raising that much money has been challenging in the siloed world of grant giving. “I can’t tell you how many times I’ve heard a statement like this from prospective funders: ‘We do health care. We don’t do conservation’ or ‘We do conservation. We don’t do health care,’” said Devika Agge, the organization’s chief development officer. “There are hundreds, potentially thousands, of grants that I can’t and don’t apply for because of our intersectional work.”

The other constraint is the limited number of years in typical grants. The nonprofit wants to help farmers plant cloves and coffee to sell, but it takes five years to grow coffee and seven to grow cloves — too long to show results for most grants.

In the world of scientific grants, three years of funding is considered solid. Five years is great. Beyond that, good luck.

For now, the Health In Harmony team in Madagascar says it is buoyed by the turnabout within the community, starting with people like Fanjanirina Pascaline Andrianandraina, or, as she prefers, “Madame Fanja.” The 56-year-old moved to the region two decades ago to join the timber industry. It was only when Health In Harmony arrived that she was forced to consider the destruction of her work.

She stopped logging and led women in her village to start their own tree nursery. They grow seedlings she sells to Health In Harmony for reforestation. And her green thumb has touched her home too. Potted plants surround the entrance, and pink bougainvillea flowers climb over her door.

When Madame Fanja looks at the Manombo reserve now, she is filled with regret. “I hope someday,” she said, “I can replace all the trees I have destroyed.”

Read More From Our Series

Roots of an Outbreak

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Part One

On the Edge: The Next Deadly Pandemic is Just a Forest Clearing Away

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Part Two

Seeding Hope: How Saving the Rainforests Could Prevent the Next Pandemic