Malnutrition in Madagascar: Pili-pili

In some of Madagascar's remote communities, a hidden malnutrition crisis is threatening young lives. Nurse Benjamin Le Dudal takes us on the road as the team works to get life-saving treatment to those most in need.

Baobab forest near Mahabo, Madagascar

To reach Ranobe by car – and thus save yourself the crossing of the Mandraré – you must first take the National 13 road, or at least what is left of it after the storms of the previous days.

If the rain, even rare, is a blessing for the population, it is for us a logistical nightmare which can double our travel times. The soil is made up of laterite – a heavy red clay of volcanic origin. It is porous and devoid of sediment, and therefore extremely sensitive to erosion.

Things get better when we head north, however, as the World Food Programme (WFP) has done some basic work on the track in order to get its trucks through and bring basic food to the villages.

In the end it takes us nearly nine hours to reach our destination, barely slowed down by the rupture of a clutch hose on one of the Nissan Patrol 4x4s in the convoy, which is repaired speedily by the drivers who are used to this kind of incident.


Ranobe is a small village surrounded by rivers and located a few kilometres from an imposing mountain range. When we arrived, there was a crowd because of the conjunction of market day and the food distribution by the WFP.

The event draws families from all the surrounding fokontanys (villages), some of whom will walk up to 25 kilometres (over 15 miles) to be there. If they are lucky enough to be on the list of beneficiaries they will have to make the return trip with several dozen kilos of rice on their heads or shoulders. (One kilo is about 2.2 lbs.)

People crowd around the vehicles and watch us set up camp. The children stare at us, their eyes wide. Before the arrival of MSF, no white people had been seen in the village since 1967, one of the elders recalls. He was only a child then – average life expectancy in these remote areas of Madagascar does not exceed 60 years.

Finding a rhythm

The local basic health centre (literally centre de santé de base, or "CSB") is no longer functional and families have apparently taken up residence in the building. Our medical team therefore set up their mobile clinic in the village's abandoned school. The teachers left the place a long time ago, when it became clear that the families would never have enough to pay them. The building is pleasantly ventilated thanks to the absence of windows and much of its roof.


Logistician Jean installs shade nets on the roof
Logistician Jean installs shade nets on the roof / Jean, logisticien hors pair, joue les équilibristes sur le toît pour installer les filets à ombre

Our team of international and Malagasy caregivers is starting to get into a rhythm. Two of us take care of triage and measurements (weight, height and mid-upper-arm circumference (MUAC)), after which the malnourished patients are referred to the doctors and nurses who determine the appropriate dose of therapeutic food to give them, and take the opportunity to treat their health problems. A final team takes care of registering the patients by hand in a large notebook with the patience of copyist monks.


The inhabitants of Ranobe live in total destitution. Many do not own even simple things like a jerry can. If we still had questions about the need for a humanitarian intervention in Madagascar, this clinic answers them without ambiguity. From the first day, we see processions of slender mothers with acutely malnourished children.

We use the term “marasmus” to describe this combination of fat loss and total muscle loss, often accompanied by bellies swollen by digestive parasites. These kids’ lives are in the balance: without food in sufficient quantity and quality, they will surely die.

It is difficult to specify how many have already died from kéré (famine) in recent months. Vital records are incomplete when they exist, and I’m told children are usually not baptised until they are 2-3 years old to avoid attracting the attention of evil spirits. Add to this the fact that for many people here, everything related to death is a highly sensitive subject, and you will understand how difficult it is to obtain reliable mortality figures is here.


The mobile clinic team camp for the night
Sharing stories from past assignments in the camp / Anecdotes de missions sont au centre des discussions au bivouac

Facing this extreme destitution, some mothers erase, with a little petroleum, the ink that we use to mark children who have already been seen by the team, so as to present them several times in a row to get a little more "pili-pili" (the local word for plumpy'nut).

These stratagies might be frustrating for us, as we try to get accurate data about the scale of the problem and make sure we have enough plumpy’nut for each clinic, but they are also understandable survival mechanisms and a sign of the desperate situations families are facing.

The end of the day

In the evening, dazed with fatigue and heat, we still have to "extract the data", that is to say, take the registers again to organise the figures in tables in the form of percentages, age groups, comorbidities, geographic origin and number of boxes of plumpy’nut consumed. This information will be transmitted to the base through the Iridium (satellite phone) during the daily debriefing.

Once this final chore is accomplished, it's now or never to take a bath in the river located a few minutes away, where it is possible to meditate peacefully in the cool water while admiring the sunset over the mountain. We must therefore avoid thinking of all the little animals that perhaps inhabit it – hookworms, bilarzhies, eels or amoebae – celebrated by our parasitology teachers for their ingenuity when it comes to getting inside a human being, either through existing orifices or by creating new ones. This is where the local people bathe every day.

The day ends with a frugal dinner of canned food or dehydrated noodles reheated on a charcoal stove. Then everyone goes to bed by the light of their headlamp. We have camp beds installed under two large tents, one for girls and the other for boys. (I caused a diplomatic incident of no consequence by going to bed by mistake in the wrong tent.)

As I leave Ranobe, I observe the savannah covered for hundreds of metres with empty packages from therapeutic food distributed by the various humanitarian organisations. Environmental awareness is a business for full bellies.


The village of Mahabo is our last stop of the week. A tragic surprise awaits us in one of the rickety shacks that serve as hospital rooms at the local health centre. A seriously injured man was brought there during the night. The nurse tells us that he is a farmer, attacked by dahalos (cattle thieves) who shot him to steal his zebus (a type of oxen). The bullet lodged in the spinal cord, leaving him a paraplegic.

With no access to a competent neurosurgeon, the poor man will not be evacuated and there is nothing we can do except make sure he gets a urinary catheter and pay for the necessary antibiotics and painkillers.

A few hours later, a crowd of around 200 brought in another wounded man. Surprised that the dahalos are now attacking in broad daylight, we go fishing for information. We learn that in reality, the man was shot after being mistaken – apparently wrongly – for a livestock thief. He will be transferred to Ambovombe in one of our cars for a blood transfusion and surgery.

After two days of working in the heat of an oven, we leave Mahabo, returning to the MSF compound for a day or two. The base has changed in our absence. It is now swarming with staff – both international and Malagasy, recruited as reinforcements for future operations.

Our goals are now to increase the number of mobile clinics and restore the run-down local hospital to its former glory so that we can transfer our serious cases there. But for that we will need drugs and medical equipment. The plane that was bringing this kit from the logistics warehouse in Bordeaux is facing administrative difficulties that escape us. It is said to be stuck on the tarmac at Istanbul Airport. Now we have to cross our fingers that the situation will resolve soon, and in the meantime we continue our activities as best we can with the plumpy’nut and the drugs we can buy locally.

Benjamin Le Dudal


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