Madagascar: Malnutrition can turn a prison sentence into a death sentence

Almost one in every two prisoners in Madagascar suffers from moderate or severe malnutrition. In 2015, more than 9,000 inmates were identified as malnourished and treated as part of an emergency food programme aiming to get this extremely vulnerable population back on their feet and prevent malnutrition-related deaths. With more than 4,000 prisoners already treated so far in 2016, the International Committee of the Red Cross (ICRC) is on track to reach the 2015 figure by the end of the year.

Madagascar was badly hit by the economic crisis and the authorities are finding it increasingly difficult to feed the country’s 22,000 strong prison population. Official ministry of justice orders specify that each inmate should receive a daily ration of 750 grams of cassava but, in reality, they rarely receive more than 300 grams.

As Brigitte Doppler, the ICRC nutritionist in charge of the food programme, explains: “It is completely insufficient, both quantitatively, in terms of energy production, and qualitatively. In the long term, if there is no other calorie intake, the inevitable outcome will be death.”

That is why the ICRC launched a national feeding programme in 2011 with the active participation of the prison authorities, who were very concerned about inmates’ welfare. Prison nurses weigh and measure all the prisoners every month and send the data to the ICRC. The ICRC analyses this data and focusses its feeding programme on moderately and severely malnourished inmates, who are examined on a weekly basis. Their recovery normally takes around three months. In each detention facility it is volunteers from the prisons’ chaplaincy association who prepare the special meals every day for the malnourished detainees.

The situation did not improve overnight. The ICRC had to overhaul the whole food production chain, improve the wood fuel supply, build better ovens, and standardize the plates and ladles used to ensure that every detainee received the right amount of food. 

Jacky Rambeloson has been an inmate at Tuléar prison since June 2015. Just one month after his arrival, he had already lost a lot of weight and was included in the feeding programme. Once he was better, he left the programme. But, back to his meagre daily ration of cassava, his condition went downhill again and, in March 2016, he was brought back into the programme. Many inmates like him are prone to lingering illnesses.

Despite the heat Jacky is wrapped up in a fleece and woolly hat. He has not gained any weight for a month. “When my weight was normal, I never had any pain anywhere. But since December I’m always cold and I feel a tingling sensation all over my body. I quickly realized that I was losing weight.” Very weak, Jacky had to be hospitalized at the end of June. The doctors suspect that he has an asymptomatic condition that was not detected because of his malnourished state.

Victorien Moha, the director of Tuléar prison, admits that he has a difficult task: “Our primary role is to avoid this kind of thing happening – deaths among the detainees. They should get enough to eat on a daily basis, despite our limited resources.”

In 2011, when the feeding programme was first set up, the prison authorities were registering around 150 deaths per year in the prison population, over two thirds of which were linked to malnutrition.

In 2015, there were unfortunately still more than 50 deaths, half of which (27) were linked to malnutrition.

Key facts and figures 

• The prison authorities’ budget has fallen by approximately 70 per cent since 2009, which has had a significant impact on the budget for feeding some 22,000 detainees.
• The feeding programme set up by the ICRC in 2011 to tackle malnutrition covers almost half of Madagascar’s 42 prisons.
• Around one third of new inmates at Tuléar prison arrive malnourished.
• The lack of food and vitamins slows the metabolism to such a point that the body no longer has the strength to react in the event of illness. That means they have no fever and no symptoms. Serious and potentially deadly illnesses and infections, such as tuberculosis or malaria, therefore go undetected.
• The poorest detainees or those who do not receive extra provisions from friends or family are the worst off.
• The special meal prepared for malnourished inmates consists of 350 grams of rice, 130 grams of dried beans and 200 grams of vegetables, to which extra salt and oil is added to help them gain weight more quickly.
• Detainees who are severely malnourished also receive, in addition to the “normal” cassava ration and the special meal, an energy paste called Plumpy’Nut.
• Local authorities and international organizations alike estimate that one in five Malagasy children under five suffer from chronic malnutrition.

Shotlist

Location: Madagascar, Tuléar prison
Length: 05:39
Format: H264 Mov HD
Production: Didier Revol
Production: Laurent Graenicher
Camera operator: Volana Razafimanantsoa
Sound: French/Malagasy
ICRC ref.: AV489N
Date: June 2016

Copyright: ICRC access all

00 00 00 The dormitory doors of Tuléar prison are opened. The inmates emerge into the yard. (6 shots)

00 29 13 Inmates carry pots of cassava to the yard. (2 shots)

00 35 19 Cooked cassava is ladled into the inmates’ dishes. (3 shots)

00 48 05 An inmates stands eating his ration of cassava. (2 shots)

00 55 00 The inmate called Marakolezy eats his ration in the dormitory. (3 shots)

01 08 16 Interview with Marakolezy, inmate – 20 sec
“This is all we get to eat here. If you get anything else it’s because you have friends or family who bring it. Maybe wheat, cassava or rice. But those of us who are poor, we just get cassava to eat every day. We have to wait for our portion from the big pot.”

01 29 05 An inmate sits eating in the dormitory.

01 32 22 Interview with Brigitte Doppler, ICRC nutritionist – 26 sec (In the prison yard, in front of a group of prisoners who are breaking up dried cassava.)
“Those who only eat this are unfortunately not getting enough for their needs, especially as they’re supposed to receive 750 grams a day. In Tuléar prison, they get 400. In other prisons, it’s as little as 200, 250 grams. It is completely insufficient, both quantitatively, in terms of energy production, and qualitatively. You can’t eat nothing but cassava every day. It doesn’t give you everything you need unfortunately.”

01 59 00 (suite) Interview with Brigitte Doppler, ICRC nutritionist – 10 sec
“In the long term, if there is no other calorie intake, the inevitable outcome will be death.”

02 08 23 Inmates squat on the ground breaking dried cassava into small pieces. (3 shots)

02 20 06 A long line of malnourished inmates stretches across the yard as they wait to enter the covered area to be weighed and measured.

02 28 14 Inmates sit and crouch as they wait their turn. (2 shots)

02 34 14 Medical check-ups are conducted in the yard by the prison nurse and Brigitte Doppler, ICRC nutritionist. (4 shots)

02 53 22 Interview with Brigitte Doppler, ICRC nutritionist – 11 sec
“This patient hasn’t gained any weight for a month. We’re going to see him this afternoon to try to find out why he isn’t putting on weight.”

03 04 13 Prison infirmary. ICRC doctor Marie-Ange Razananantsoa and the prison nurse examine the inmate Jacky Rambeloson. (6 shots)

03 27 19 Interview with Jacky Rambeloson, inmate – 10 sec
“You die if you don’t eat. This is what happens because we get so little to eat. And I can’t stop thinking about my problems. So if there’s no food either, it’s certain death.”

03 38 02 Interview with Jacky Rambeloson, inmate – 19 sec
“When my weight was normal, I never had any pain anywhere. But since December I’m always cold and I feel a tingling sensation all over my body. I quickly realized that I was losing weight.”

03 57 02 The director of Tuléar prison talks to the inmates before they are shut in for the night. (3 shots)

04 13 19 Interview with Victorien Moha, director of Tuléar prison – 22 sec
“As the director of this establishment, our primary role is to avoid this kind of thing happening, to avoid deaths among the detainees. They should get enough to eat on a daily basis, despite our limited resources.”

04 35 17 Food is prepared for the malnourished inmates. (7 shots)

05 05 13 Interview with Brigitte Doppler, ICRC nutritionist – 10 sec
“This is the extra meal for the moderately malnourished inmates. Rice, beans, oil, vegetables. That gives them 2,400 kilocalories.”

05 15 02 The special meal is handed out to the malnourished inmates. (7 shots)

05 38 22 End