Malnutrition in Madagascar: Narrow paths

Nurse Benjamin joins an "explo" - an exploratory trip to remote corners of a region experiencing a nutritional crisis...

The drivers on motorbikes

- "We are tired, vazaha."

The young man had crouched down beside his machine, his eyes dark. He refused to continue. We had recruited our two bikers in Tsivory the day before. After fording several rivers and trudging through the tall grass, pushing and pulling the motorcycles on steep and sandy banks, then trudging through the savannah for nearly three hours, the two drivers only wanted to turn around. They hadn’t been expecting a ride like this.

I looked at the GPS map and consulted our guide. Both were clear, we had made it three quarters of the way. Only five kilometres still separated us from our goal, the small isolated village of Ambatomanaky. Turning back when we were so close would make no sense and wouldn't bode well for the rest of the week.

An exploratory trip

An exploratory trip is one of the most emblematic activities of MSF projects. It mainly involves logisticians, water & sanitation specialists (WATSANs) and medical professionals. The principle is simple: send a small team to areas where we aren't familiar with the situation in order to bring back all the information that is lacking: what access to water do people have; what are the security conditions, diseases, the state of the health facilities?

Very often, the team leaves for the week, travels by 4x4 or motorbikes and bivouacs in the bush if necessary.

In the blink of an eye

The day begins in the early hours of the morning with the smell of gasoline from the freshly filled tanks. We leave Tsivory at the first light of day, crossing the still-deserted streets as the first shutters of the coffee shops open. In the blink of an eye the city is gone. The motorcycles go smoothly on the paved road.

On the verges, workers stop to watch us go by, spades slung over their shoulders and hands shading their eyes. We discover a landscape of hills, tall grass and trees that are unfamiliar to me, gilded with fine gold by the rays of the rising sun. Far to the north, a vast mountain range blocks the horizon.

A string of communities unrolls before us in decreasing size. Starting from a small town, we will soon arrive in a large town, then it will be just villages and hamlets. We are a group of three. It's the medical advisor, a translator and I.

In the capital

Our goal is to reach the most remote and difficult-to-reach villages in the municipality of Elonty to assess the nutritional situation there during this time of food crisis.

In the capital, we take the opportunity to visit the basic health centre. The nurse there welcomes us with open arms. The number of malnourished children is constantly increasing and we are still far from the annual peak, which corresponds to the lean period between harvests.

You have to make your way through the tall grass, cross dying rivers and hoist the bikes with the strength of your arms to the top of the banks, trying not to let your feet slip in the sand...

He asks for our help following the departure of another NGO last month after a security problem in the area.

Before leaving and venturing into the bush we feel it safer to complete our team with a local guide. Even the GPS maps are imprecise here. The road soon fades into a path just wide enough to allow the passage of a zebu (ox) cart. We progress along an old colonial trail that nature has patiently regained since independence, forcing us to slalom between collapsed portions and giant termite mounds.


Under the wheels, the treacherous ground alternates between hollows and bumps, sometimes covered with a carpet of moving stones that unbalance both drivers and their passengers. Soon the route narrows further to become just a path, one that the inhabitants of the region take on foot to get from one village to another.


Arriving at Ambatomanaky in the smoke of slash-and-burn cultivation / Arrivée au village d’Ambatomanaky dans la fumée d’un feu de brousse (culture sur brûlis)

You then have to make your way through the tall grass, cross dying rivers and hoist the bikes with the strength of your arms to the top of the banks, trying not to let your feet slip in the sand, before getting on them again, sometimes only for a few hundred yards before a new obstacle arises. We are only progressing at five to seven kilometres per hour. A man in a hurry would easily get ahead of us on foot, especially by using shortcuts drawing secret geometries in the bush.


We have almost reached our goal when our bikers suddenly go on strike. They are exhausted. We all are. I speak to them, say that we are a team and that we have to finish our trip as we started, together. One of the bikers turns to his colleague: "courage-do!” he implores.

I promise them two very cold and well-earned beers in addition to their salary once the trip is finished. They get back in the saddle. Our modest expedition can continue. “Where others don't go”. This slightly pretentious old MSF slogan seems to take on its full meaning as Ambatomanaky finally appears.

The region has experienced recurrent episodes of drought. But this one has been going on for three years...

The village is surrounded by a palisade of cacti with only one or two entrances, the width of a man to be easier to defend against intrusions. Inside the enclosure, a few mud houses with straw roofs, some rice and peanuts hanging out in the sun to dry.

The president of the fokontany, a dry man in his sixties, invites us to sit in the shade for a chat. Women install mats. Most of the villagers are in the fields, the others form a circle around us so as not to miss any of our discussions.


The children stare at us with wide eyes: we are told that we are the first white people to have come to the village.

We ask the chief about the living conditions in his fokontany. He tells us that they manage to grow some peanuts, cassava and sweet potatoes, but crops are poor due to the lack of rains.

The situation is the same everywhere: insufficient harvests, surface water that you must drink even if it makes you sick...

As far as living memory is concerned, the climate has always been stingy with water here and the region has experienced recurrent episodes of drought. But this one has been going on for three years.

Several families have left for the city or for other northern provinces. The village does not have a pump or a well. People drink the water from the nearby river, the colour of which is enough to explain why all the children here have big bellies. Many diseases, including intestinal parasitosis, are carried by water.

A few children are malnourished, but none appear to be in danger. Most are seen weekly at the Elonty dispensary where they are given plumpy’nut. At least they are when the health centre is stocked, which is not the case now. It is then eight hours of walk there and back under the sun to finally come back empty-handed.

The chief insists on inviting us to eat, but we politely decline, highlighting the long road ahead so as not to delay.


The following days, we continue our reconnaissance in other isolated fokontanys: Beadabo, Maroforoha and Tamotamo Bas. The situation is the same everywhere: insufficient harvests, the monthly WFP rations of which there is nothing left after 15 days, surface water that you must drink even if it makes you sick. And everywhere we are told about these families who left by the dozen. It is not uncommon for villages to have lost a third of their population since 2019.


Along the river
Besakoa River is where villagers have to collect their drinking water / La rivière de Besakoa où les villageois recueillent leur eau de boisson

Around Besakoa, 90% of the rice terraces are dry. In the village square, children play, rolling bicycle rims with a stick while the adults watch from the shade. Maybe they remember the sweet recklessness of that age, or are they thinking about the future of these kids?

The chief of a hamlet asks me to intercede on his behalf so that his people get a well and maybe some food. I explain that this far exceeds my decision-making power, but I promise to pass on his request. He pronounces a sentence that Naina, the driver, translates to me by rolling the Rs: "He says thank you for coming to see our little village, thank you for taking an interest in our lives."


Our guide leads us steadily to the isolated village of Maroforoha. Maroforoha is located at the foot of the mountains. After two hours on the motorbike, we have to finish on foot, guided by an old bushman who carries only his clothes and a knife, going barefoot through the river and the savannah, taking us after him.

- “Before, there were more than 100 people here. We had 800 zebus!" remembers the toothless chef who greets us. I am surprised.

- "When was that?"

- "In the 80s…"

Since that time, relentless cattle raids and drought have done their work. There are only a few dozen people left in Maroforoha and there is not even a chicken left to steal. The chief tells me that the “dahalo” (people who steal cattle) have taken everything and sometimes come back to take the little rice brought from the city, stealing kitchen utensils or threatening villagers with death for money.


The guide walking leading the way through the long grass
Our guide leads us to Maroforoha / Notre guide nous mène d’un pas sûr vers le village isolé de Maroforoha

A razor's edge

The neighbouring village of Mazoharivo is abandoned. We pass several of these ghost hamlets, whose houses are crumbling behind cacti and weeds. “People will come back with the rains,” we are told. But will the rains come back?

The road to Tsivory passes at the foot of Dada-Be Matori, literally “the sleeping grandfather”, a mountain whose profile in fact evokes an elongated old man who seems to observe the sky peacefully. The thunderstorm season is coming to an end. The southern winter is coming and with it the lean months.

In the evening, Mélanie the medical advisor and I talk at length about the perspectives of these men and women who cling to their land no matter what. Their health needs will have to be watched closely, as they are on a razor's edge, and to ensure that their situation does not take an even darker turn.

On our return, we formulate our recommendations to our superiors: repair the out-of-service pumps in Besakoa, rehabilitate the Tsivory hospital which is in a sorry state, deliver the plumpy’nut from the government to the health centres so that they do not run out.

No doubt also opening a new mobile clinic in the region. This will all be a patch on a colander, but it is essential.


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