Fieldset
Malnutrition in Madagascar: My last clinic

Nurse Benjamin Le Dudal writes from the end of his assignment in Madagascar's nutrition crisis...

Tents in a circle. NB. The photo in this blog post are all in colour - a contrast to all of Benjamin's other posts which are in black and white

The road to Mahaly was more difficult than expected. A 15-person convoy with Plumpy'Nut, tents and luggage does not move on Malagasy paths with the same ease as a light pick-up.

Mahaly

We arrive in a sleepy little town. A few children kick a deflated balloon while a bunch of idle teens watch us get out of our Médecins Sans Frontières / Doctors Without Borders (MSF) vehicles.

Mahaly was once one of the wealthiest towns in the south. In recent years, it has lost much of its population due to drought and cattle raids. It is now one of the poorest and most underserved areas in the district. After some hesitation, we set up camp on the school grounds, closed due to COVID-19. This is one of the few places in the city where we find land relatively untouched by the problem of open defecation.

Passing the baton

In the morning, we leave for Behareno, a village that we had identified the previous week as a priority site because of its distance from the Mahaly dispensary and the prevalence of cases of malnutrition.

On the bumpy road, we watch the sunrise over the mountain-fringed savannah and I realise this is my last trip to a mobile clinic. I try to observe these landscapes through the eyes of Sinan, a newly arrived nurse who is seeing them for the first time. During the week, my task will be to give him the necessary information to enable him to take over my role in the field. I am torn between a real relief in passing the baton and a feeling of leaving while our task is still incomplete.

 

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MSF nurse Sedra training the team

Questions

So much remains to be done and improved. So many questions remained unanswered. Now, during our distributions, in addition to Plumpy’Nut, a high-calorie therapeutic food, we distribute soap and jerry cans.

Soon it will be rice, oil and pulses to prevent the children from relapsing into malnutrition for lack of food at home.

Does it make sense to distribute albendazole (a medication that gets rid of parasites) to children in villages where, for lack of a pump, they will be re-infested in a week by drinking water from the river? What are the alternatives ? Is there another agency that could provide drinking water here, while our teams focus on medical care?

Will it be easy to disengage from a country where famine is a constant threat and where, in many communities, people only survive on food distributions?

Should we introduce the cultivation of cereals that consume less water than rice and corn, at the risk of becoming involved in ecological interference? Opt for a daring agricultural policy, with construction of irrigation canals and distribution of seeds? Would that be enough? Or will the villages continue to gradually empty and the Great South to become desert, victim of the first clearly perceptible effects of climate change?

These questions are outside of MSF’s remit, but having worked on the nutritional crisis here, it’s hard not to think about longer-term solutions.

Behareno

In Behareno, I find the villagers who welcomed me during our explo. They are delighted to see us returning in large numbers to give medical care to the children. The chef's wife insists that I taste the cassava dish she has prepared.

The team at the second mobile clinic is now well established and impressively efficient. We set up arbors and shade nets in less than an hour. Sedra passes on the tricks of the trade to Sinan, from calculating the Z-score of our data to the intricacies of the register where we record key information. For my part, I take advantage of a quiet period to take some pictures and write down my impressions in my notebook.

Last night with the team

On the way back, I buy two chickens to organise an improved meal with the team. It’s my last night with them and therefore a special moment for me. Evening is falling in the bush. The full moon rises over the hills, lighting up the surroundings like in a movie scene shot on an American night.

While Charles is lighting a campfire, Naina brings the Nissan Patrol closer, which begins to churn out full-blown Madagascan music. Everyone is gathered, drivers, nurses, logisticians and nutritional assistants. I take this opportunity to toast my colleagues and the work accomplished together.

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The campfire

Some of my colleagues are from around the world and some are from here in Madagascar. Together we have explored the region in 4x4s, on motorcycles and on foot, crossed a river in a raft, slept in tents, cooked around a campfire and help multiple meetings as we worked to address the nutritional crisis here.

A good reason to get up

I also remember the smiles of the people I have met, their generosity and the strong impression their courage and tenacity have made on me. During these three months, I’ve rarely stayed in bed after 6 a.m. but getting up so early was (almost) never difficult because each time we had a good reason to get up.

There were plenty of challenges. Of course, not everything went as planned. For a long time we ran low on medicines and equipment and even today we are not able to treat all the pathologies that we encounter in the field. Despite the frustration generated, it was also an opportunity to learn, and a lot. I was immersed in the principles of emergency nutritional intervention and was able to put my knowledge of tropical medicine into practice.

I had to understand and accept the responsibilities of my role as a supervisory nurse, which is very different from my work in France, to learn on the job how to supervise a team, while participating in the organisation and logistics of our activities.

One day

Will I do another assignment with Médecins Sans Frontières? One day, no doubt.

For the moment, my thoughts are on France and those projects of yesterday and today that I look forward to realising: writing, travelling as a couple and starting a family.

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