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Understanding natural resource extraction in Madagascar is key to developing wider conservation and management strategies that ensure the continued delivery of essential ecosystem services, and the development of health and economic strategies to meet the demands of a growing human population. In the Kianjavato lowland rainforest of southeastern Madagascar, 78% of lemur species, 83% of native carnivoran species, and 67% of frugivorous bat species are threatened with extinction. All three of these groups of mammals are commonly hunted for food in other regions of Madagascar, yet we knew little about current levels of hunting or whether the use of forest resources significantly affects human welfare in this region. We used health assessments of 1 267 Kianjavato residents and semi-structured interviews of members of 336 households in 1 7 communities in Kianjavato to investigate human-environmental interactions. We found high prevalence of child and teenage malnutrition. More than half of the population under 20 years old was stunted, more than half was underweight, and more than one fifth was wasted. Further, one in six residents were anemic. We found that Kianjavato’s forests provided essential ecosystem services for its rural communities. As Kianjavato’s forests are altered to meet the needs of a growing human population, these direct-use ecosystem services (such as the use of wild animals for food or plants for medicine) are unable to similarly expand to meet the basic needs of the families living in these forests. A worrying proportion of the Kianjavato population depends on forests to meet their healthcare, nutritional, and economic needs, yet they may be failing to do so. All surveyed households (1 00%) depended on forests to meet their healthcare needs and 40% of the regional economy involved the extraction of finite forest resources (i.e., precious stones). Most households consumed very little wildlife (two animals per household per year) and the great majority (83%) of the forest animals they ate were not threatened with extinction. Forty percent of wildlife were caught illegally. Although hunting is likely not imperiling local wildlife at present, 1 6% of the Kianjavato population hunts wildlife and 20% are malnourished. The ecosystem services of Kianjavato’s forests may currently be insufficient to meet the needs of residents. Therefore, targeted efforts to increase local access to the healthcare system and to improve household nutrition and economy by improving the production and stability of local agricultural products may increase the long-term sustainability of wildlife hunting, household incomes, and regional food security. Efforts such as these that can expand with the growing population to meet future needs may help secure the sustainable use of essential ecosystem services for the long term, improving the health of local people and maintaining the integrity of the forests in which they live.