travel bursary reports
Mandritsara is a small remote village in the north east of Madagascar and I fell in love with it. It is located in the North East of the country in the Sofia Region and the last census estimates it contains a population of about 17,000 people ¹. At the heart of a community of villages in Mandritsara is situated a mission hospital which has been around for twenty years, called Hopitaly Vaovao Mahafaly (HVM) and this is where I spent my elective.
The thing about living in a small rural village there is that there isn’t a whole lot to do. There are no shopping centres, no cinemas, no bars, no clubs, no theatres. What there is, is a complete and real sense of the beauty of unimpeded nature, the serenity of simplicity, the truth of poverty and joy and hard labour. Everything is grown, everything is fresh, everything is homemade. Nothing is imported, nothing is packaged, nothing is ready made. This forced me to live life in slow motion again, and in doing so I learned to pay attention to the detail, to discover the personality of this unique community which became my home for a number of unforgettable weeks.
Mandritsara is surrounded by a multitude of red rolling hills and as result is often referred to as a ‘crater’ - as though God saw it fit to interrupt the endless landscape of peaks to scoop out a portion big enough to house a small community of villages. The people of Mandritsara are mainly of the Tsimihety descent, which, literally translated, means ‘those who do not cut their hair’. As such many of the women have long braided hair which is often wonderfully fashioned into neat buns and knots, worn up in order to facilitate work under hot temperatures. They are mostly small-framed and dainty in appearance which completely disguises their surprisingly strong physical ability and the ease with which they have learnt to tackle arduous labour, mostly involving work in the rice fields. There are many rice fields in Mandritsara, so a significant number of its people are in the business of growing rice. This also quickly explains why rice is the staple food. Spend a few days there and you will soon find it is completely reasonable to consume rice in the morning for breakfast, in the afternoon for lunch and then at night for dinner, every single day.
Nevertheless, what will vary is how the rice is served and what is eaten alongside it. This reminds me of my own perception of the African continent; like the presence of rice in every dish, there will always be striking similarities between the manifold nations that make up this vast continent, but look a little closer and it’s easy to appreciate the many differences too, that surround and complement the very core they have in common.
Like the women, Malagasy men also tend to be short in stature but strong in physique. In fact, having spent several weeks living in Mandritsara, I could not find a single overweight individual. Within ten minutes of landing in London, I had seen three. I wonder what truthful conclusions can be drawn from this striking contradiction and whether we will truly ever understand how or why such vast differences are allowed to exist.
The ugly truth is poverty is rife in Madagascar. I do not need to quote the statistics to be certain of this fact. I need only to think of the seven year old girl with marasmus, her thin flailing limbs, her whispy brown hair, her black peeling skin to know it’s there. I think of the young mother and father who have to take their newborn baby home to die because they can no longer pay the hospital fees that’ll keep him alive. I think of the fifty year old woman who is bed ridden, immobile, dying after ignoring a lump in her breast because she literally couldn’t afford to do otherwise. I think of the four year old boy with every textbook sign of severe calcium deficiency. I think of a family of six sharing a room half the size of my own. I think of the time I threw away half a kilo of rotting meat because I had forgotten to freeze it and couldn’t contemplate cooking it, only to find the cleaners rescuing it out of the rubbish bin and diligently scrubbing off the mould, eager to take it home to their families to eat. All of these images and so many more, ensure I know that poverty is ever present and ever brutal. In fact it is so endemic that it becomes the norm, and it’s in becoming the norm that I become guilty of forgetting that it shouldn’t be.
Sure enough, wherever there is poverty, there is also wealth and it would be painting an incomplete picture to omit that. A good number of Malagasies in Mandritsara live comfortably and often the wealthier members of its society are those who either own a lot of cattle or those who are highly educated. And then there are the missionaries.
This year, Hopitaly Vaovao Mahafaly celebrates its twentieth year of existence. Literally translated this means ‘the hospital that gives good news’. It is renowned in this part of Madagascar and the sick come from far and wide to be seen here. The hospital building is extremely sophisticated compared to the infrastructure of the rest of the village, and consists of five main areas – the medical ward, the surgical ward, the maternity unit, the operating theatre and the outpatient unit. The medical and surgical ward each hold around 40 beds. Beds are extremely close to one another, in order to fit as many as possible into the small wards and this often leads to a lack of privacy between patients. However this always seemed to be completely culturally appropriate. On each ward, there are a couple of small side rooms normally used for isolating especially infectious patients which some wealthier patients were able to hire at additional cost. Even at this mission hospital, healthcare is not free at the point of use. Patients are required to pay for treatment, although this is heavily subsidized to provide fares more affordable than that encountered at the government hospital. For a minority of patients, who are extremely poor, or who suffer from long term conditions such as diabetes or sickle cell anaemia, the mission hospital has established a ‘Poor Fund’ to provide free long-term treatment. Because of its missionary status there is an important focus on sharing the Gospel of Christ and providing an exceptionally loving standard of care. For this reason, it has become renowned in this part of the country and many would travel days to be seen there. It is an incredible establishment, built on the principles of love, care and benevolence. Before the ward round every morning, there was a time of sharing scripture, song and prayer. After breaking bad news, or when patients were anxious, the staff would often offer counsel or prayer. Faith and spiritual wellbeing was completely integrated into medical and surgical care and I had never encountered a group of professionals more dedicated and selfless in their desire to serve the physical, emotional and spiritual needs of a community. They have mastered the art of using little to do much for the many who come to seek their help. However, this has also given rise to a very particular, very unique and very distinct micro-community of missionaries within this rural Malagasy region.
In my experience, hospital staff were always broadly categorised into two groups to reflect this characteristic – either Malagasy or missionary. Over the years, the concept of a missionary has become synonymous with the description of a ‘white’ person or as said in Malagasy ‘vaza’. It is easy to understand why this distinction has occurred – there is a strong missionary presence made up of long-termers and short-termers, families, couples and individuals, young and old, male and female, some doctors, some surgeons, some nurses, others teachers, but all Caucasian. So when I, a young westernised, educated, female, black British- African arrived to join this missionary team, I was unknowingly making history. The vast majority of villagers had not ever encountered a black person who was not of Malagasy origin, who sounded like a vaza and lived with the vazas. I was an anomaly. I was a walking paradox and had not anticipated to be viewed as such. There were those who looked at me with eyes full of admiration – they were proud, I had made it and if I’d made it, maybe someday they would too. Their pride made me uncomfortable, I felt as though I was being perpetually congratulated for cheating the system, the trouble is, I wasn’t sure how I had managed to and I certainly didn’t feel like I had deserved to either. Some however, I could tell, resented me for what they thought I stood for – a privileged snob who lived behind guarded walls in missionary houses, who thought herself superior to her own kind. And whilst such judgements would frequently overwhelm me with a sense of profound irrational guilt, I was simultaneously glad I’d ended up on the safe side of the wall, shielded from the brutality of poverty, the lack of comfort and the reality of death.
Death became a familiar face. It could be old or young, the teenager or the toddler, the strong man or the young mother. The first time I began to accept the illogical, raw, vicious and unforgiving nature of death was when an eight year old boy was brought in by his parents after a short history of fever and vomiting. The little boy was crying and attempting to fight of the nurses trying to insert a cannula into his tiny veins, but we were relieved by his protesting; this meant he wasn’t drowsy, he was alert, kicking and screaming. A couple of hours later he was dead. He had suddenly succumbed to internal bleeding due to a perforated bowel secondary to typhoid fever and like that, his eight year old body lay limp. Over the subsequent number of weeks, this was not an uncommon occurrence; death would come, sometimes far too unannounced and unexpected, other times slowly and affirmatively, most times leaving us with the full knowledge that, were our patients born in a different part of the world, their chances of survival would be exponentially increased. Here, the odds are not in their favour.
According to the CIA World Factbook, fifty percent of the population of Madagascar live below the poverty line and it is ranked 218th in the world according to its GDP per capita ². According to the WHO, the total expenditure on health as percentage of GDP is 4.2% ³.
The disease burden there included common infectious diseases such as malaria and typhoid fever. The latest statistics show deaths due to malaria to be around 27 out of 100,000⁴. There is also a significantly high prevalence of schistosomiasis, predominantly as a result of the climate and working environments. Culturally fertility is highly praised and according to WHO data, in 2013 the total fertility rate per woman was 4.5 ⁴. However this masks, the often greater numbers in the more rural areas.
I think of the Millennium Development Goals and I think of these eight promises that were made to the world fifteen years ago. I think of how obvious it is that Mandritsara finds itself so heavily falling short of every single one of them. I think of human nature which is so prone to forgetting, to greed, to selfishness and cowardice. I think of the Ananse story in every one of us. I often think about the many patients I encountered during my time at HVM. Their individual circumstances, stories and struggles and the invitation we have as medical professionals to effect some aspect of that. In particular I am reminded of a woman I met named Bernadette.
Bernadette had been brought in to hospital, lying on a makeshift stretcher, carried on the shoulders of various relatives. After taking a brief history via a translator, I gathered that she had presented following the chronic loss of the use of both her legs. She blames this on a fall she had nearby a river some months ago. As I proceeded to examine her physical state, the root of her ailment became apparent well before I could get as far as her lower limbs. I had noticed a severely deformed left breast which was ridden with grossly abnormal tissue, a mixture of necrotic material and hardened abscesses. There was no doubt this was a breast tumour which had been allowed to spread unimpeded and now harboured all kinds of bacteria and fungi. Immediately, I realised it was already too late. It was obvious this was breast cancer which had metastasized throughout her body and it was the most likely cause of her paraplegia. I completed my examination and found multiple enlarged hard cervical and axillary lymph nodes, as well as the most severe pressure sore I could ever have imagined. This woman had lost all movement and sensation in her legs bilaterally and was urinally and faecally incontinent. She was homebound and bed ridden without any access to medical care, being looked after by family members who tried to do their best to meet her needs. Unfortunately, this had lead to her developing an incredibly impressive grade four sacral pressure sore – and because she had no sensation in the area, she was practically unaware of its existence. Staring at the 20 cm wide and 7 cm deep foul-smelling, pus-filled, necrotic sore which was deep enough to expose her spinal vertebrae, it was intensely shocking and upsetting to think how easily this could have been avoided. It was too late for her and there was little the hospital could offer to help; there was no radiotherapy and no chemotherapy. In the end, she had to be sent home to die.
It is tempting to enter a new environment simply with the intention of comparing and contrasting it to the thing I am used to. Undoubtedly Madagascar, and more specifically Mandritsara is plagued with an immense burden of preventable disease and troubled with a lack of adequate access to effective and affordable healthcare. There is a clear need across the region that the government’ health system is failing to meet, and that Hopitaly Vaovao Mahafaly is striving to alleviate. And while this small missionary hospital in the middle of rural Madagascar may not be a perfect solution, it is there to affirm to the people of Mandritsara that they deserve to be cared for well.
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