One of the First

Madagascar’s National Highway 13 has not been repaired for many years. The drought has wiped out the past two harvests, and no more rain is expected before November.

People are walking 10-20 km on a daily basis for the chance to sell some charcoal or a few pieces of sugarcane or cactus fruit. The cassava does not grow as it should. It grows just a few inches high on dusty, small patches of earth surrounded by crooked leaf cactus with big white spines. The corn has dried out and is as sparse as pine trees in a forest clearing.
About half a million people live in the area where the food crisis is worst. Nevertheless it is a sparsely inhabited area. The villages are small and inaccessible. Highway 13 runs through one of the world’s forgotten corners. In this case the corner happens to lie in southern Madagascar, but the road might as well run through any of numerous other poor areas around the globe.
The people here are hardened. They are accustomed to chronic malnutrition. Poverty is widespread and the living conditions offer no consolation. An empty stomach is nothing unusual here.
Malnutrition hits hardest those who are most in need – always the smallest children. They do not grow as they should. They become weakened and vulnerable to infections. Because the roads are so bad and the capital, Antananarivo, is so far away, the food here costs five times more than in the capital. In the past few weeks, the most desperate have begun to eat cactus fruits to get in a little sugar.
What is happening here is not a natural disaster. It is not war or an infectious epidemic. Malnutrition is a personal disaster that gets played out over and over again, in family after family. The slow drama captures no interest among the mass media.
It is not the first time that a child has followed his mother along the sandy paths, when the sun is highest in the sky, on spindly legs, with a pair of emaciated arms which no longer have the energy to scratch his sparse, flea-infested hairline. It is not the first time a child has tried to relieve a hunger-gripped distended stomach by chewing one piece of sugarcane for hours at a time. But, nevertheless, it is a disaster for this child and for his mother and father.
The room where I sit and write these first lines are filled with a sound that I recognize. It is the sound of raindrops hitting the window panes in the hospital where I work at home. But no rain falls here. The sound I hear is my fingers hitting the keyboard. I’ve decided that these lines, and all the rest that follow, will be the voice of the children in Madagascar and of the women and children who do not have enough to eat and do not have a voice strong enough to shout so that the rest of us can hear.
Central African Republic (CAR). Before I came here the name conjured up for me dark scenes of civil war, senseless killing and gruelling poverty. I was nervous. Not least because I would be living and working using my basic French. I did my research, read back through the news stories of the last few years and various opinion pieces, it was almost unanimously grim.
When I told friends and family where I’d be going the common response was “Oh Central Africa, but which country are you actually going to?”
Despite being one of the most volatile countries in the world, CAR remains largely unknown and in some ways a forgotten emergency. Forgotten by some, not all. Médecins Sans Frontières has been here since 1997 and with 16 projects in the country is a leading healthcare provider. Impressive, but also a reflection of the depressing state of affairs in a country larger in size than France & Belgium together.
The project that I am working on is a town on the CAR side of the border with Democratic Republic of Congo. It has previously been a flashpoint for armed rebels who have left their mark on the town. However, the situation here is currently calm and we and the local population are enjoying the relative stability.
In the hospital is the maternity ward, where I spend most of my days and the occasional night. The cases are the usual mix of normal deliveries, emergencies and surprises. The midwives here manage to get the babies out though.
Whether they are coming head first or breech, they will encourage and motivate until the little thing is screaming its lungs out. In sub-Saharan Africa a caesarean section can be lifesaving but is also a scar that will be carried for life. The risks of complications in future pregnancies (here women are often having over 10 pregnancies in their lifetime) make it a decision to be taken with caution, and usually only once alternative options have been exhausted.
Much more challenging than getting these babies out is the situation with unwanted pregnancies. A subject often considered as taboo, but responsible for a high proportion of maternal deaths. On my very first day in the capital, Bangui, a woman presented to the hospital with an abortion. Already in septic shock, she died.
The reality for women here, where contraception is either hard to access or not accepted (for example by a husband or mother-in-law) is that abortion is the other form of birth control, but one that comes with high risks. Often performed in the community by “traditional” methods the women come to us with signs of poisoning, trauma, or overdoses of conventional medicines. The illegality of all this means that getting any reliable history from the patient is like getting blood from a stone, leaving us to make presumptions and guesses. And at the end of it all, often the pregnancy remains.
Together with my midwife counterpart we are training the staff here to recognize and react to the women presenting with abortion complications. Having workshops for our national colleagues on the signs of sepsis and emergency treatment, running regular drills in the department and increasingly giving the responsibility of management to them.
Together we are making sure that, for whatever the reason, these women get quick access to lifesaving treatment and procedures. And just like getting those babies out, this is met with a genuine enthusiasm, so much so that we have now accomplished a major milestone; national staff providing training to the other staff. Skills not just learnt, but being transferred too.
Yes, CAR is volatile and challenging. But dark, no. For the women who make it to us there is care and compassion. And though I am just a passing ship, I remain proud to be witness to the light that the department shines out.
One of the Last
Kibera. Although I have visited Mombasa, and spent way too many hours in transit in Nairobi airport, this is my first time in the city itself.  It reminds me a lot of Johannesburg.
As a side project, I am working on a qualitative research study to explore perceptions of Medication Adherence Clubs, or MACs.  Qualitative research, in general, which focuses on words rather than numbers.  I ask people ‘why’ and ‘how’, rather than counting ‘how many’.  The MACs are a quick, easy way for patients in and around Kibera to collect their medication.  Rather than spending a whole day waiting in the clinic, they come once every three months to collect their drugs in a group of up to 30 people.  The drugs are pre-packed and waiting for them in rows of named, brown paper bags, like takeaways lined up on the counter of a fast-food restaurant. The volume of medication amazes me sometimes: I have become so used to seeing this sort of innovative, that I often have to step back – it’s not right.
Children come in masses to our vaccination sites which have been placed all over the region. They stand in the shade of mango trees, in empty buildings, in schools.
We walk there, we travel by car and motorcycle, we go by boat, we paddle and we ride bikes. They come because we have engaged local people, village elders, priests and other key employees. We knock doors and announce our immunisation campaign with a megaphone, as well as on the radio.
All this to reach as many children between six months and 10 years as possible. This kind of campaign is not uncomplicated. The live, but attenuated, measles virus contained in the vaccine must be kept cold all the time to survive and be effective. It is not easy to achieve a cold chain of vaccines from France to the smallest villages out in the Congolese countryside.
What awaits the team, I do not know at the time of writing. But certainly we will follow the epidemic until the end of it.
Summerlily Highwater
Critical Care Trauma Obstetrics and Gynecology