Fieldset
Malnutrition in Madagascar: Into the “healthcare desert”

Nurse Benjamin Le Dudal takes us along with a mobile clinic team visiting remote villages in Madagascar's crisis-hit south

An MSF team arrive at the village of Ranobe in Madagascar

The MSF flags on the handlebars flapped in the wind as the motorcycles raised a trail of dust that sparkles in the first rays of the sun.

The track passed along the bottom of dry wadis and small rivers, before going up on the plains and passing at the foot of four majestic baobabs.

To the west, the landscape is barred by a large rocky plateau that evokes the Lost World of Conan Doyle and which I'm told local rumours suggest is inhabited by cultists. Even taking this with a pinch of salt, I have to acknowledge that the sparse population and remote location means that potential practitioners of a forbidden cult would find here the discretion required for their meetings.

However, if we had chosen to come here, it was because of alarming reports that people in the area were starting to starve.

Sacred places

It took four hours by 4x4 to reach Ebelo in Ambovombe, a small town without running water and where electricity is accessible only within the limits of what the solar panels can provide.

By the side of the road, we passed a few men on bikes, axes on their shoulders, and women in their brightly colored lamba: slender silhouettes with very straight bearings who turned slowly so as not to spill the contents of the buckets or baskets balanced on their heads.

Not looking like zebus or those who guard them, we did not have to fear these men as long as we avoided driving at night

Sometimes the vegetation gave way to solid structures, surrounded by wooden palisades studded with zebu (a type of cattle) skulls. These are the tombs that house the remains of the ancestors, whose rest is disturbed only for the famadihana – the ceremony of turning the dead during which they are dressed in new clothes.

These are highly sacred places where, I was told, it is not good to take photographs, at the risk of joining early the spirits reputed to roam the area.

The dahalo

Once in Ebelo, we crossed the central square of the village, surrounded by a curious crowd.

Among them, a man who looked like he was experiencing an episode of mental illness, walked less easily with his feet tied up by a wooden yoke. In the absence of anti-psychotic medication, I was told that the People's Court had opted for this solution, which at least left the possibility for citizens to distance themselves from the "nuisance" (who had, as far as I could verify, a clear tendency to pinch people’s food and to demand cigarettes).  

The locals followed us into the town hall, thronging both doors and windows so as not to lose any of the discussion between the vahazas (foreigners) and their mayor.

The latter explained to us that the food situation was becoming critical in several villages in the region and that a gendarmerie commander had been killed and several people seriously injured during an attack on the village by cattle thieves (dahalo) just days ago.

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The team meet with the mayor of Ebelo
The team meet with the mayor of Ebelo

We were told that, not looking like zebus or those who guard them, we did not have to fear these men as long as we avoided driving at night. The gendarmes in sandals and army shorts that I passed did not seem to show signs of anxiety either. And, if they did indeed appear downcast that evening, I was told it was after watching the defeat of the national team to Ethiopia, in the only bar in the village with a television and the sonorous jeers of the geckos reverberating around them.

The healthcare desert

From Ebelo, it takes another hour for two-wheelers to reach Ankamena, a small hamlet made of wooden shacks and located under the magnificently photogenic – and possibly infrequently visited – mountain which was mentioned above.

Since the first healthcare centre is 25 kilometres away, it takes half a day's walking for mothers to take their children there to be vaccinated against measles. A series of stretchers and carriers apparently exists to transport the most urgent cases, but there are delays and the path is in poor condition.

The objective of a mobile clinic is to provide care to people living in the middle of such a healthcare desert.

In this case, the task of the medical team was to identify the most malnourished in order to offer them treatment and therapeutic food. Children under the age of five are the focus of our attention because they are the first to die of hunger and the infections that accompany it.

In no time, a crowd of mothers, children and the elderly gathered. We triaged the most severe cases and quickly admitted small children with bellies swollen by intestinal parasites who no longer had any strength. Nurses measure the children's MUAC (mid-upper arm circumference – a useful indicator of malnutrition), weight and height.

Unfortunately, some of the drugs we ordered were still on their way, but in the meantime we worked with homemade rehydration solution (water, salt and sugar), amoxicillin, albendazole and a little paracetamol.

Then comes the distribution of plumpy’nut, a high-calorie therapeutic food, which will not solve the problem of crops wiped out by drought and locusts, but it will at least keep the weakest from starving until we return in two weeks.

Waiting under the leaves

As the nursing manager, I oversee the organisation of the measures and make sure everyone has what they need to work. While the logisticians erect a roof of leaves so that waiting families have some shade, I distribute water to the children and ensure everything is going smoothly, giving a hand with measurements or consultations where needed.

We are beginning to better understand the situation we are facing. This is not a generalised famine… but rather a very acute food crisis affecting very specific areas

I also have to make sure, and this is a thankless task, that the people who are less malnourished and who do not meet our criteria understand that they will not benefit from waiting for a consultation at this moment.

Some would, however, benefit from medical or surgical care. These include an older man with a glassy eye whose glaucoma we are at the moment powerless to treat, or the many children with umbilical hernias, possibly due to inadequate cord care.

The babies are marked with a little ink to keep track. In these regions where humanitarian organisations operate, plumpy’nut is found in markets and has its own price, just like rice or corn.

Once the distribution is over, some young girls start singing and dancing, improvising a show, to the encouragement of one of our doctors.

At first shy, they gradually gain confidence and are joined by other children. The feet strike the ground in rhythm, the voices mingle in a polyphonic and repetitive melody, vaguely hypnotic. The moment is outside of time.

Under the blazing sun

After two days of clinic in Ankamena, we head towards Ranobe. To do this, you have to cross the Mandraré river that separates the two villages.

The week before it was still possible on a motorbike, but the waterway swelled due to the storm rains. Our team will raft or ford it with water up to their chests. And, once you reach the opposite bank, you still have to walk 30 to 40 minutes under the blazing sun with a 14 kg box on your shoulder.

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Crossing the Mandraré river to reach Ranobe
Crossing the Mandraré river to reach Ranobe

Once in Ranobe, people flock by the hundreds, waiting in the heat until it is their turn. A little girl plays with a loosely carved piece of wood in the shape of a human effigy. A patient adolescent squatting, leaning on his spear.

The proportion of severe acute malnutrition is very significant here. Sometimes whole families have nothing to eat and only eat brèdes plants. Our clinic team is becoming well-oiled and we work continuously for five hours, until it gets late and we have to leave.

An acute crisis

Gradually, we are beginning to better understand the situation we are facing. This is not a generalised famine such as Somalia experienced in 1992, but rather a very acute food crisis affecting very specific areas.

The World Food Programme distributes food here, but only half-rations and sometimes only rice, which risks causing vitamin deficiencies such as beri-beri. In any case, the trucks do not reach the most isolated villages and the lists of beneficiaries are no longer up to date.

According to our estimates, only 300 residents of the town out of 7,900 would have benefited from the last distribution.

Following this trial run, we returned to the MSF base to stock up on supplies and medicines. Next week we are scheduled to head back into the bush to return to Ranobe and attempt to reach even more distant hamlets.

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