Malnutrition in Madagascar: Life, death and drums

Cut off from affordable healthcare, families living at the heart of Madagascar's food crisis face difficult decisions. Nurse Benjamin Le Dudal shares the experience of one mobile clinic team taking treatment to the people.

A local health centre, currently closed

The inhabitants of the village of Tomboarivo are obviously music lovers. During the three days that we stay there, never more than a few hours pass without the beats of percussion resounding somewhere.

It took us eight hours of travel to cover the some 200 kilometres of bumpy track that lead to this fokontany (village).


La rivière entre Marotsiraka et Tomboarivo
Only a trickle runs in this vast river / Seul un petit filet d’eau circule encore dans cette vaste rivière

On the road, our convoy passed only a few children, perhaps ten years old, leading small herds of goats and zebus through the vast mountainous and semi-desert expanses that extend beyond Ebelo. The shepherds watch us go by, frozen in place and often too astonished by our sudden appearance to greet us.


A short break in Marotsiraka allows us to see that this county town has – in addition to a large church, with, to my eye, a vaguely Mexican appearance – a borehole and a water pump powered by solar panels. This is a rare sight in this region where such installations are often stolen.

The horizon is barred by mountains with slender curves that rise above the plain like motionless waves

This water supply makes growing food for market possible and, in fact, the village is surrounded by a reassuring crown of greenery. It is even possible to find a little rice spread out to dry in front of the houses.

Further on, the landscape takes on a more austere allure, alternating between the desert road and the low vegetation of the scrubland. Our 4x4s cross so many dry rivers that I gave up counting them. The horizon is barred by mountains with slender curves that rise above the plain like motionless waves.

Welcome to Tomboarivo

We finally reach Tomboarivo in the middle of the afternoon. An exploration team scouted the scene a few days earlier and found malnourished children there.

When we arrive, I head for the Maison des Jeunes (youth club), where a crowd has gathered. A local association gives a small concert mixing djembe drum, guitar and song to the delight of the teenagers of the village who invite themselves to the performance.

I take this opportunity to let Oliver, the head of the association, know that we have arrived, so that the information circulates to the surrounding hamlets.

In addition to the town hall and the basic health centre, there are only a handful of solid buildings in Tomboarivo, some of them in ruins. The houses are built of earth and their roofs covered with leaves. The school, as often, is no longer open since the departure of the last teacher. The Malagasy flag flutters limply at the top of its mast.

Around the central square, coffee, donuts and single cigarettes can be purchased inexpensively from small wooden stalls run by two or three generations of women chatting side by side.

Setting up

The mayor tells us that the population of the fokontany has been halved since this episode of malnutrition began. Three years without rains triggered an exodus, sending several thousand people out on the roads to seek greener pastures, towards the coast or far up to the north. The mayor thanked us for our presence and gave us permission to pitch the two large tents, one of which will serve as a dormitory, the other as a consultation room.

Joaquin, an experienced logistician, stocked up on rice, vegetables and chickens along the way, so the team should have enough to eat.

While he is fine-tuning the installation of the site, I am organising a small training session for the Malagasy doctor and the two nutritional assistants who have joined us this week.


The entrance of the village
The entrance of the village / A l’entrée du village

Market day

“Mora mora!” Albert, the driver who is now responsible for regulating the flow of patients, yells in his megaphone. This means both “slow, slow,” and “take it easy”.

It’s market day and it’s busy. Women rush into the holding area, holding the hands of children with thin arms and swollen bellies walking behind them.

How many children die like this for lack of affordable community care?

In these rural communities, the market is the unmissable event around which the week is structured. It is a place of exchange – of goods as well as of information – and also a party that often lasts into the night, because those who come from far away sleep there.

The village square is crowded with people. The crowd forms a circle around a troupe of dancers, three girls and three boys, who bustle to the frantic and repetitive music of a trio of musicians. Perfectly synchronised, seemingly insensitive to heat and fatigue, they lift the powdery earth into a state close to trance.


Dance and music in the market square
Dance and music draws a crowd / Les danses et la musique attirent la foule

The cost of care

In the screening area, we see children whose number and general state of health is not as worrying as our initial estimates led us to fear.

However, several of them require treatment, some urgently. A 16-month-old boy is dehydrated and severely malnourished. We will transfer him to hospital in one of our vehicles for specialist care.

In theory, there is a network of basic health centres where patients can go to receive care. In practice, not all of these are operational. Some are just a memory, while others continue to welcome patients but lack equipment and supplies.

The Tomboarivo health centre nurse was killed last year and his replacement, a young graduate full of goodwill, does not have enough medicine and Plumpy’Nut – the peanut-based paste often used to counter malnutrition.


Consultations in the tent
The consultation tent / Les consultations s’enchaînent sous la grande tente

Then comes the question of cost. Several diseases are the subject of national programmes, such as malaria and acute malnutrition. The treatment is then free, but not the equipment used to administer it (such a syringes, etc.) which remains the responsibility of the family.

If the patient's condition is worrying, he must be taken to the CRENI, a specialist malnutrition centre, or to referral hospital located in Tsivory, sometimes a day's walk or a taxi from further away.

The cost of round-trip transport, not to mention accommodation and food on site, quickly becomes prohibitive for these poorer families. And, if MSF had not paid the bill, it's a safe bet that the mother of this 16-month-old child would not have been able to afford the transfer to Tsivory hospital.

How many children die like this for lack of affordable community care?

While having my coffee around 5:30 am, I observed that very morning a funeral procession leave the village at the first light of day, accompanied by lamentations and tears. A seven-month-old child had died the day before.

On “explo”

Our day ends after eight hours of consultations.

“Miasa tsara,” I say to congratulate the team, making the nurses and assistants smile, just like every time I say a few words in Malagasy. I think it’s my accent.

Villages just a few kilometres apart can vary from satisfactory to catastrophic

In the evening, while lying on my cot, I can still hear the distant sound of percussion coming from a neighboring hamlet, the intensity of the beats rising and falling according to the direction of the wind.

As we begin a new day of work on site, two logisticians and a doctor go on an “explo”. Their goal is to visit other fokontany to see if MSF's mobile clinics should move there.

The situation is tense. A village chief was kidnapped that very morning. I’m told this is a common process: the kidnappers then claim 1-2 million ariary to free the hostage, and families have no choice but to sell their land to raise that amount.

However, without having spotted an area where our intervention would be required, the decision was made to return to base to regain strength and give ourselves time to reflect.

Debrief and decisions

On our return, I was pleased to see that the international cargo had arrived and the drugs were patiently put away by our pharmacist. Unfortunately, we still lack many drugs, among them the most useful. It will be in a month until the second plane lands.


Football match
Tomboarivo football match / Partie de foot à Tomboarivo

The coordination team brings us together for a debriefing. MSF was built around large meetings where everyone, whatever their status, can express their opinion on the operations in progress and the choices that remain to be made. This is a tradition that has continued, not always without disagreements, because the NGO is made up of strong personalities and deep convictions, and sparks sometimes arise when their visions clash.

The agenda is the strategy for the next few weeks:

At several recently opened mobile clinic sites, the number of malnourished children is not as high as might be expected. Supplying Plumpy’Nut could perhaps alleviate the problem?

Rather than spreading our resources across a multitude of villages where the needs are not glaring, should we not continue our reconnaissance in the most difficult to access places of the region? To understand the situation and possibly redeploy there.

Villages just a few kilometres apart can vary from satisfactory to catastrophic, and neither government figures nor rumours can reliably predict the situation. The best solution is still to go and see for ourselves.

The next morning, I take advantage of having some time, and call the doctor who took care of the child we transferred just few days earlier.

He’s out of danger.


This post is part of a series. You can read the first post here. To see all the posts, click here.