ANKAVANDRA, 17 June 2011 (IRIN) - Ankavandra is a one-car town in western Madagascar, so when the all-terrain 4x4 vehicle arrived recently it did a lap of honour around the sports field, watched by scores of applauding residents.

The arrival of a car in a town that has become almost disconnected from the Madagascan capital, Antananarivo, about 230km to the east, briefly disrupted the training of a local militia being raised by the gendarmerie to help combat the increasing incidents of stock theft in the district.

It was also cause for celebration after Air Madagascar's twice-weekly flights - which used to land on a rough airstrip an hour's walk from town and a ferry ride by pirogue, a shallow-draft canoe, across the Manambolo River - ended in July 2010, leaving people in the area with a sense of having been abandoned.

Although the flight was unaffordable for most residents in desperately poor Ankavandra, with its rutted roads, and no electricity, sanitation or reticulated water, it provided a lifeline for medical supplies during the rainy season from December to April, when the region's main town is effectively cut off.

Ankavandra's only general practitioner, Dr Simone Rasoanjanahary, who is responsible for the healthcare of about 13,000 people, told IRIN that public health services had largely remained unchanged since March 2009, when Andry Rajoelina, with the support of the military, deposed President Marc Ravalomanana in an illegal transfer of power.

"Because of transportation links there is a lack of medicines - in the rainy season it is most acute," she said. "This year a truck was meant to come in April, but because the rains finished late, it only arrived in May." Among the stock-outs were anti-inflammatory and anti-allergy drugs, penicillin and painkillers.

Isolation

Ankavandra sits at the base of Madagascar's central plateau. The contour road to the east - built by the French colonial government to ascend the central plateau that rises more than 1,000 metres and transport the coffee crop to Antananarivo - was long ago consumed by landslides. A plan to rehabilitate the road in 2007 never got off the drawing board.

To the west, the Manambolo River hems the town in and the absence of any bridges makes crossing it during the wet season treacherous. The only land route from Antananarivo to Ankavandra is a circuitous 500km road through Beravina, of which the last 100km or so are dirt roads that become all but impassable during the rains.

Rasoanjanahary admits her surgical skills are limited to stitching small wounds, so anything more serious - from infected crocodile bites to injuries resulting from overturned ox-carts - requires evacuation.

"In the old days we used the plane [for patients], but now there are no more planes. If there is a truck [delivering supplies to the town] they might be able to take them, or it means carrying a person by stretcher to Tsiroanomandidy [about 80km west on the plateau], which takes about 48 to 52 hours," Rasoanjanahary said.

In such circumstances a case of appendicitis is, more often than not, fatal, but for one woman a visit by Hoveraid, the only NGO that operates in the Ankavandra area, it was little more than a brief medical procedure in a traditional society that still places great store in the power of amulets.

Peter van Buuren, the country representative of Hoveraid, a faith-based organisation whose motto is "reaching the unreachable", told IRIN the poor local communication infrastructure was not only a problem for its residents, but also for relief organizations.

The NGO uses hovercraft to navigate the country's rivers, which are not suited to conventional boats because shifting sand bars and shallows often make them impassable.

Nevertheless, Van Buuren said, "there are only a few areas where hovercraft are suitable", but around the world, from Madagascar to Papua New Guinea, there are 30-50 million people in need of assistance in such environments, and during wide-scale flooding the vehicle has few peers.

Hoveraid is mainly a facilitator enabling health workers to provide treatment and has also assisted other relief organizations, such as Oxfam and World Vision, to reach remote areas using hovercraft.

In conjunction with another faith-based organization, Mission Aviation Fellowship (MAF), flying in the medical teams into remote areas, Hoveraid provides medical assistance to isolated communities using local doctors from Antananarivo.

Van Buuren said the NGO visited Ankavandra about four times a year for five-day stints, but "this is more like an emergency operation than development."

The organization provides similar medical assistance in Beroroha, situated along the Mangoky River in the south, where it estimates about 90,000 people live with practically no access to health care, as well as in Anjabetrongo on the southwest coast, Sahakevo in the west and Ampansinambo in the east.

Preparations

About a month before the medical team arrives, local administrators are informed using the short-wave network - there are no cellphone networks - and patients are drawn from a wide area through word of mouth.

A family of four - Hasina, 38, his wife, Mitezusou, 25, their one-year-old child and four-year-old daughter, Pelamina, who has a lipoma (a benign fatty tumour) on her back - walked for 31 hours to get medical help.

"In Ampasibe [a village of about 700 people] there is no nurse, no midwife or doctor. Pelamina has had this growth since she started crawling," Hasina told IRIN.

Like many other patients arriving at the clinic, Pelamina wears an amulet around her neck, provided by local healers to ward off evil spirits. The 30-minute operation under general anaesthetic to remove the lipoma is a success and now the accusations of sorcery by her peers and their parents will end.

Jean-Louis Solohery, 28, arrived in Ankavandra from Soalaka, about a six-hour walk away, but just under an hour by hovercraft. For the past year an infection of the scrotum, probably bilharzia related, has caused it to swell to the size of a small football, but he has also been treated.

In the four and half days the clinic is held, the six-person medical team, including surgeons, dentists, student doctors and an anaesthetist, perform 114 surgeries and a further 301 consultations. Fewer surgeries - 50 to 60 - were performed during their visit in December 2010.

"There were many hernia operations on children and this was because there was insufficient protein in their diet, causing poor muscle development," Dr Helivah Rajaobelison, 25, a trainee surgeon, told IRIN.

Solar panels provide power for the clinic, held in the town's tuberculosis (TB) centre, where surgical operations often proceed late into the night. Smaller surgeries are performed the next day using daylight while the batteries recharge.

Dr Sylvain Rasolofonirina, a retired general surgeon heading the medical team, told IRIN that "the operating conditions are fair but not good. There is a big need for surgery, as it is a remote area and the level of medical expertise is limited."

All the necessary medicines, such as drugs for sexually transmitted infections (STIs) - which ran out in the first few days - intravenous drips, operating equipment and a sonar scanner are flown in with the team.

Although they can perform a variety of procedures, from circumcisions to repairing a botched year-old hysterectomy, there are limits. A 70-year-old man, his lower lip disfigured to the size of a kilogram of raw meat and displaying all the signs of cancer, was one patient that the medical team could not assist.

Limitations

"The kind of surgery we can perform is only of a certain level," Rasolofonirina said. "It is not the same as we can perform in Antananarivo. We are here to help people and we know the risks of surgery. We could not operate on the old man [with a cancerous lip], as we cannot do blood transfusions and he could die on the operating table.
Another woman, her stomach grossly distended, was diagnosed as having either cancer of the stomach or a TB infection, but the medical team was unable to make a precise evaluation, as they did not have the facilities to perform a biopsy.

"The consultations take time - it is not only about giving medicine, it is also about talking to people about prevention," said Dr Clement Ralison, a member of the medical team.

Among the common ailments in Ankavandra are schistosomiasis (also known as bilharzia), anaemia, malaria, respiratory infections and tapeworm infestation, caused by poor hygiene and undercooked meat. Cattle and pigs roam the streets and although boreholes have been dug, many people still draw water from the Manambolo River.

Left untreated, cysts from the tapeworms - essentially larvae - can lodge in the brain, causing debilitating headaches, convulsions and death, Ralison said.

Community workshops are held to stress the importance of regular hand washing, cooking meat thoroughly, using mosquito nets, and providing information on how to prevent STIs.

Source: The Integrated Regional Information Networks (http://www.irinnews.org )