Malnutrition in Madagascar: "Explo" life

Nurse Benjamin and the team continue their work to find the areas of the country most affected by malnutrition...

An MSF 4x4 Land Cruiser car

We emerge from our tents around 6 a.m. The mocha coffee maker soon purrs over the wood fire. In silence everyone swallows the hot liquid facing the mountains and it all looks like an expedition of Italian mountaineers.

We break camp and load the 4x4 before heading north-east, through a landscape of scorched savannah and dry rivers. Apart from a few standing stones, there is no trace of human construction until the gaze comes up against the distant responses of the earth. Not a plane in the pristine sky.


The savannah north of Mahaly / La savane au Nord de Mahaly
The savannah north of Mahaly / La savane au Nord de Mahaly

There are four of us in the car. There is Santatra, our warehouse keeper who has agreed to serve as our translator, Patrick, the driver who expertly leads us on the steepest slopes, and finally Joaquin, the experienced logistician whom I managed to convince to accompany us on this new feat despite his busy schedule at the base.

This reconnaissance trip should allow us to identify the areas where malnutrition is hitting hardest in the commune of Mahaly, located in the far north of the district. This data will then allow the project managers to decide where to send our mobile clinics.

Vohitelo and Behareno

Vohitelo is a small village with mud houses which look like they might one day collapse without warning. The children are initially cautious, but gradually approach when they see Joaquin and I talking quietly with the head of the fokontany. The situation he describes is worrying. Due to a lack of sufficient crops and without WFP distribution nearby, people eat barely edible tubers which they call makalioso and which make them sick. We identify several malnourished children and learn of at least two deaths related to kéré in the past month. The health centre, it seems, was out of Plumpy’Nut.

We continue our journey to the next fokontany, Behareno, which we reach after 1h30 in our 4x4 and 10 minutes of walking. The situation is not any better there. Besides hunger, the villagers tell us about the raids of the dahalos, men armed with rifles who arrive in their dozens at night and take everything they can find, from food to kitchen utensils. "We only have two pots for the whole village," explains one of the women in the group. They also evoke, with embarrassed laughter, the rapes and kidnappings of which they are sometimes victims.


Collecting info
Collecting information with the village residents / Recueil des informations auprès de la population du village


In the evening, well after dark, we sit down in the only restaurant in Mahaly, the village where we have set up our camp. Joaquin makes the kids of the village laugh by showing them a clip from the cartoon “Madagascar” on his phone. We then debrief our day over a dish of pasta, and find that we agree on the need to bring a team to the area.

Around 7 p.m., we are suddenly alerted by screams and hurried footsteps. It seems that dahalos have been seen near the village. We move back towards the gendarmerie post. A man orders me to turn off my headlamp to be more discreet.

A few minutes later, we hear a single shot, probably fired by a villager to warn the armed men that the village is ready to defend itself. The tension subsides and soon we hear again the conversations of the adults and the games of the children. As a precaution we sleep fully dressed, ready to evacuate quickly in the event of a problem.


The next day, we leave on motorcycles to the village of Babaria, located in the far north of the area. Everyone we met warned us that access would be extremely difficult, if not impossible, and we advised against attempting the journey. We have gathered alarming information about this area located near the mountains, about eight hours walk from the capital of Mahaly.


Fixing the machines
Fixing the motorbike / Conciliabule des motards autour de la machine récalcitrante

After about an hour and a half riding on the rough track, one of the motorcycles breaks down. Joaquin dismantles the spark plug to clean it and the machine starts up again, before stalling a few kilometres further. This time, the entire carburetor is removed and cleaned, but the machine stubbornly refuses to restart.

On foot

Unable to ride a motorbike, I insist that Joaquin continue towards Babaria, taking the guide and translator on the other two bikes, so that we can still get the job done, despite the breakdown. During this time, the remaining driver and I begin the return trip on foot, taking turns to push the bike, which has become a dead weight.

I am suddenly seized with a doubt.

- "Misy rano ianao?” (Do you have water?)

- “Ah, tsisy,” answers the other with a look of distress.

I unscrew the lid of my flask: there is 600ml of water to split between my companion in misfortune and I. I am not worried because given the distance travelled, we should make it back to Mahaly before dark, even on foot. However, my colleague and I agree that we will ration ourselves because there is only one river on our way back.

Back to Mahaly

I wipe the sweat from my eyes. In the distance, the sides of the mountains form magnificent drapes. We walk silently, pushing the bike on the climbs and holding it back on the descents. The silence is only broken by the wind which rustles the tall grass.

We reach the river after three hours of walking and the driver listlessly decides to try his luck with the motorbike again. Unbelievably, it starts. No doubt a problem with the engine overheating that has been rectified by this long break, which has allowed the engine to cool.

Delighted to fly over the last kilometres, we get on our capricious steed and lash towards Mahaly without thinking twice.

We meet Joaquin in the evening. He couldn’t reach Babaria either, due to the condition of the track. He had to give up seven or eight kilometres from the goal, for fear of not being able to return before nightfall. He was still able to visit a hamlet not far from there, where the situation was not as dire as our information had suggested. This recognition will at least have confirmed to us that the access conditions are too difficult to send a mobile clinic there unless it is dropped off by helicopter (which neither MSF nor the Malagasy army have access to).

In Mahaly, we meet the head nurse of the health centre. We deliver 40 boxes of Plumpy’Nut to him which had been stuck in a town further south due to the condition of the road. With these new deliveries we hope that the dispensary will be able to take care of both the children in the nutrition programme as well as those that we referred to it following our explo.

The evening

The atmosphere is calm at the evening meal. We are exhausted. Joaquin draws his cigarette thoughtfully.

- If the only outcome of the day is that the little girl with SAM [severe acute malnutrition] is registered, it won't have been a day wasted.

I nod.

He resumes after a pause:

- When I was in the Central African Republic I had to talk to a nurse who was in low spirits. She'd got to the point where she only saw the negative in the project. What we didn't do, what we couldn't cure. I told her that helping even one child is something. I think she needed to hear that.

Then, without me knowing if he's still talking to the nurse in Central Africa or me, he adds:

- This kid's mother, you know, she doesn't just walk away with therapeutic food. She returns home with a little hope, the knowledge that she and her family are seen as human beings.

The International Space Station

At the end of our trip, we return to the MSF base in Amboasary where the team is being enriched with new colleagues, who arrived after a long quarantine in the capital city. Others, like me, will be leaving soon as our visas are about to expire.

For international staff, an MSF assignment involves living and working with about ten people or more, for a period of three, six or even nine months. A living arrangement that is both a Spanish hostel and a stay on the International Space Station.


Saturday night at the base / Samedi soir à la base
Saturday night at the base / Samedi soir à la base

Some of these colleagues are humanitarian professionals who string together assignments like seasoned pilots accruing flying hours. They are a valuable asset to the team. When a question or difficulty arises, they take the memory of a past experience out of their hats and twist it like a wire until it fits perfectly to the present situation.

Alongside them we are fortunate to have on the team Malagasy health care workers whose determination, thoroughness and efficiency have never ceased to impress me during my time here. Charles, one of the nurses, explains to me that he is very proud to work for MSF and thus have the opportunity to “help his people”. For him and his colleagues, it is also the opportunity to be able to do a job that he is passionate about. The Madagascan Ministry of Health does not have the means to pay several nurses in each dispensary and many of them work there as volunteers, a courageous choice but one which does not allow them to provide for their families.

New international staff, of which I am one, are called “First Assignment”. For many, this first humanitarian experience will also be their last. Statistics show that most First Assignment international staff never return. Everyone has their reasons. The Spartan daily life on the ground, the separation from loved ones and the confrontation with suffering and death are all things that one must have lived to know how to endure them.

Happiness is not maths

Humanitarians are an ephemeral community made up of extremely different personalities. We meet former scouts and ex-punks, old soldiers and young graduates, engineers and mechanics. All are travellers and have ridden their bumps around the world. Many like challenges and will know how to fascinate you with their stories. What brings them together? The search for meaning, the desire to help, but often also an aversion to routine and the same thirst for elsewhere.

"Happiness is not a maths," wrote Gionio. Two and two don't make four for everyone."

In the evening at the base, when the light fades and the beer cans are blown with a lighter, the anecdotes come together. These are funny or dramatic stories, tragic like human life, through which everyone tells a little about themselves. As for me, I am about to leave for my last week in the field, in the company of the newcomers to whom we will pass the baton.


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