Proof positive

Madagascar may be one of the poorest countries in the world, but outreach and education are bringing big change.

Story and photos by Kasey Jackson

On a recent visit to Madagascar, Kiwanis donors and leaders were introduced to UNICEF programs throughout the country, including those focused on medical, education and sanitation issues.

They met mothers. Children. Families. They heard about the problems these families face: Extreme poverty. Chronic malnutrition in children, especially those 5 years of age and younger. Lack of education. Lack of resources. Lack of access to clean water.

They also met health-care workers. Some who are paid. Some who volunteer their time to make a difference. And most of whom have tales of traveling hours and hours to reach families in the farthest reaches of this island nation.

And maybe most memorably, they met countless healthy moms and babies who are receiving health care, including protection against maternal and neonatal tetanus.

The process—though a tough one faced with many obstacles and sometimes painstakingly small steps—is bringing positive change in Madagascar.

Kiwanis International President Gunter Gasser visits young schoolchildren in Belo Tsiribihina, Madagascar. Nearly 80 percent of the population lives in poverty here, with most people unable to afford adequate nutrition or access to health care.

Boots on the ground

The crowd of curious onlookers grows deeper as the strangers descend upon the town of Belo Tsiribihina, Madagascar. Malagasy women, wrapped in brightly colored scarves known locally as lamba, line the wall of a simple concrete building, babies resting either on their hips or tied securely to their chest or back. Small children, most without shoes, stand looking wide-eyed at the visitors, who all are wearing the same color: blue. The area where they all have gathered is quite small, a dirt alley of sorts. The visitors, UNICEF staff and Kiwanis volunteers, have come to this spot to meet a young mother and her baby—to hear and see the success of MNT elimination efforts.

Dr. Victoria Tsilimbiaza Faranasoa (above) says the immunization rate in Belo Tsiribihina has improved because of outreach programs instituted by herself and other health workers. “This is my contribution to improve the welfare of the population, of our neighbors,” says the doctor, shown below in her office.

Smack dab in the middle of the swarming crowd is a young woman, clothed in a cream and brown dress suit, hair pulled back and secured tightly with a clip. She wears a simple gold cross around her neck and flat dress shoes. She smiles warmly at the women and the growing crowd of children. It’s likely she knows most, if not all, of their names. She is, after all, the town doctor.

Dr. Victoria Tsilimbiaza Faranasoa greets a mother and her young son in the crowd. The mother, son balanced on her hip, hands the doctor a small paperback book and certificate. The doctor flips through the pages of the book, smiles and nods, and then hands everything back to the mother. The women exchange a few words in Malagasy, and then, a moment of pride: The mother holds the certificate up for all to see, and for the visitors to snap a photo. It’s a small, colorful piece of paper.

It’s her son’s vaccination certificate.

Women here hold these immunization records close—many have them tucked safely into plastic bags for safekeeping. But as these mothers greet the visitors from UNICEF and Kiwanis, they’re happy to show off their papers. After all, they’ve come out to thank the visitors, to meet them … to see who it is who is helping them keep their children healthy.

As the group adds new members —now not only UNICEF staff and Kiwanis volunteers, but the doctor and other local health workers have joined the parade—it heads out on foot toward the doctor’s office at the health center. When they part ways, the families, many still feeling shy but curious, wave and look away quickly, only to sneak a peek back at the visitors who have come to their town. Children laugh and skip. Some take off running. The mothers slowly disperse to head back to their homes, the youngest kids scampering alongside, leaving a dusty poof of air at their feet as they go.

The heat of the day is rising and the scenery is unforgettable during the walk to the health center. The roads here are of a mix of red dirt and clay, a sharp contrast to the bright colors of the clothing, green trees and brilliant blue sky. School is letting out for the day and children in vibrant blue smocks fall in line behind the Kiwanis donors and leaders. Farther down the road, there’s a sign made of simple wooden planks and arrows leading the way to buildings housing the town dentist, hospital and health center. Turning to follow the arrows’ directions, one thing is clear right away: The doctor is a very popular woman in this town.

There’s a line of patients waiting.

Madagascar’s overall health system is poor, but doctors and health workers are determined to overcome the odds. Consultations with families at health centers offer education about everything from vaccinations and proper nutrition habits to the importance of using mosquito nets.

The doctor is in

Victoria Tsilimbiaza Faranasoa straightens some papers on her desk inside her office at the Belo Tsiribihina Health Center, a slight breeze wisping through the open window behind her. As with most buildings in Madagascar, this window has no glass, simply a cutout in the wall adorned with a fabric curtain, tied in a large knot. Sunset is almost upon the town, casting a colorful hue outside the health center as the doctor sits down to tell her story. It’s almost an hour since the group arrived back at the center, and the doctor has seen the last of her patients. For now.

Dr. Victoria, as she is known, keeps quite busy in this town of about 30,000 people. She wakes around 5 a.m., prepares food and gets her 7-year-old daughter ready for school. Before she leaves for the health center, there’s already a growing number of patients lining up outside of her home. She’ll see every one of them.

She heads to the center around 8 a.m., when she sees more patients and fills out patient reports. Around 11:30 a.m., she goes home for lunch—only to find more patients waiting there. After lunch and consultations at home, it’s back to the health center around 3 p.m., where she’ll consult with patients until around 6 pm. Once she leaves for the day, she’s still not finished: She sees patients at home once again from 6 to 8 p.m.

At 8 p.m., she eats and visits with her daughter. Soon after, it’s time for a little television to catch up on the news, and around 9:30 p.m., she falls asleep.

“I do nothing special,” she says, shaking her head, a huge smile on her face. “I feel tired. But it’s my habit, I’m used to it.

“Since I chose to be a medical doctor, I chose this task. I accept it.”

From nutrition programs in the town of Andoharanofotsy (above) to vaccination drives in Tsimafana and Belo Tsiribihina (below), dedication of health workers is paving the way to improved access to all types of health care.

Whatever it takes

Tsilimbiaza Faranasoa grew up in Morondava and went on to train for eight years as a medical doctor at the University of Mahajanga in the northern region of Madagascar. Once she received her medical diploma, she worked for a nongovernmental organization. Then, in 2006, she started at the health center.

As is the case in most areas of the country, the top three ailments she sees patients for are respiratory issues, diarrhea and malaria.

“Here in the health center, there are 60 to 80 patients each day,” she says, “and they have to wait a long time. Some patients prefer to wake up earlier in the morning to see me at my home. Or in the evening. But I must register each patient, even those seen at my home. And I treat about 40 to 50 cases of malaria a week.”

She also works hard to keep the families in the town healthy even when they aren’t at her doorstep needing treatment. Of course, vaccinations, including those for tetanus, are high on her priority list.

And she offers reminders: There are posters hanging around the health center advertising the importance of immunizations.

“We vaccinate about 40 to 60 children a week,” she says, “along with 10 to 15 pregnant women. We have many health activities every day in the center, but when we receive funds from UNICEF, for example, we can do outreach activities. Our team goes out to remote areas to reach families, primarily for our vaccination program.”

But getting to the families who need help isn’t always easy—or cheap—which is exactly why funding from organizations such as UNICEF and Kiwanis is so important, she says.

“The most difficult thing for us is reaching the families who are far away. If we don’t have enough money to buy fuel for the boat, we have to take a canoe, and it takes almost one day to get there. One day to go, one day spent there, and one day to come home. And that takes staff away from the health center.”

But she’s dedicated—and almost nothing can keep her from helping those who need help most. But, unfortunately, it isn’t always lack of money and resources standing in the way.

“During Mother and Child Week in October of 2010, when we came back from a very remote area, there were gangs who attacked us,” she recalls. “They thought we were shrimp sellers because of our coolers. There were four of them. I had to go hide, but one person started to take everything, my bag with my telephone, money, jewelry. So the rest of the vaccine, they threw it out. They beat me on my back.”

During this trip, she and several other community health workers were able to escape mostly uninjured, but were left with the reminder that doing their jobs on a daily basis can be very challenging.

“I appreciate the cooperation I get from the community health workers,” she says. “The work we do together is good. The community health workers help me with my daily work. And the population here also accepts the advice given by community health workers. Recently, a vaccination program ended and the community came together to prepare food for us, to thank us. The community members followed us to the river to say goodbye as we got on boats to leave.”

Making progress

No matter what story Dr. Victoria shares, she shares it with the widest of smiles on her face. She’s content here, happy. She has a mission and a goal and she goes about it 100 percent. Every day. She knows what she’s doing is making a difference, no matter what sacrifices she makes or how many hours she puts in a day. And there are always positive memories to outweigh the negative ones.

One in particular stands out.

This area where the doctor works, Belo Tsiribihina, has seen a remarkable number of women being vaccinated against tetanus—93 percent. This is quite a victory for everyone.

“Almost all the women accept the vaccine, and they know tetanus is very dangerous, which is why they accept to be vaccinated,” she says. “That’s why we have good coverage for the campaign. We do education and messaging here even before consultations.

“But it’s important to give money not only for the vaccine first, but also for the outreach activity … because it is very hard for the health worker to reach the women living in the remote area, because we don’t have enough resources to go there. That’s why it is important to get help from donors. It’s so important.”