The child’s stomach is swollen hard against his skin, beginning to push the belly button out, a pregnant woman’s roundness on a five-year-old boy. There is a medicine that will kill the worms inside him, but no point in carrying it.

“The worms will return before I do,” says Dr. Randria Vivien Razafindrabary. “Always they return.” He looks for something he can cure, and finds a lung infection. For that, there is medicine in his backpack.

The next child also has worms. Dr. Vivien squats and looks into the boy’s dark eyes. They are big, open eyes, wonderful child eyes as happy as any anywhere because they do not know there is a way of life that doesn’t involve looking out at a stomach swollen with parasites.

“The worms spoil the blood,” says Dr. Vivien. “They slow the growth. He is ten years of age.” The boy looks five or six.

---

If you’ve played Risk, you know that Madagascar is an island off the southeastern tip of Africa. Most people probably also know that funky primates called lemurs come from Madagascar. You might have some idea that the country about the size of Texas is one of the world’s most ecologically odd places — more than 80 percent of the plants, 90 percent of the reptiles, half the birds and nearly 100 percent of the mammals are found nowhere else on earth.

And if you know anything at all about beauty you can guess that the magnificence of Madagascar comes with a price. But you probably don’t know the specifics. You don’t know that when a seven-mile-long swarm of locusts settled on the island this year it was pretty much business as usual in one of the world’s poorest, harshest environments.

Only about one-tenth of Madagascar’s rainforest still stands. The rest has been burned to clear the land for small, tribal farms or to create vast corporate plantations of sisal, a white fiber without a decent market since the introduction of synthetic versions.

In the north and southeast the bare topsoil washes away during the heavy rainy season, leaving erosion, rock and barren dirt. The southwest is a huge desert that receives rain only a few weeks in December and January, but the hardscrabble tribes that have lived there for almost 2,000 years won’t abandon their homes.

You don’t know that 40,000 people died in the last round of famines. You don’t know that about 85 percent of the children are undernourished even during the best times. You don’t know that mountain bikes might help change all of this.

---

The singletrack that weaves away from the village of Esaka was not made for mountain bikes. It was worn by 40 generations of feet going to and from a trickly creek. On this ancient footpath Dr. Vivien rides a bike that seems almost as ancient by American mountain biking standards — a two-year-old, $299, rigid-forked Mongoose Threshold — but in Madagascar it is unbuyable technology.

The Mongoose was one of eight shipped to Madagascar in 1996 by Pedals for Progress, a U.S. nonprofit organization that has collected more than 20,000 used bike and delivered them to poor countries such as Nicaragua, El Salvador, Ecuador, Namibia and Fiji. For most of its projects, PFP accepts any bike with two wheels and no frame rust, but only real mountain bikes will work in Madagascar.

Working as a group called ASOS — Action Sante Organization Secours, or “health, help, action organization” — Vivien, two other doctors and their assistants use the bikes to ride into remote villages speckled amid the 1,000- to 2,000-foot mountains that border the town of Tolognaro. Some of the villages can be reached only by footpath — three-fourths of Madagascar can’t be reached by car or truck. Other villages border dirt roads that rain transmutes into flowing mud rivers impassable by motorized vehicles.

ASOS owns a battered Rover but even in fair weather driving is impractical. The gas supply is unpredictable, and before a trip the doctors drive from town to town looking for a place to fill the ten-gallon tanks they keep in the back of the truck. And the price of gas often spikes to $4 a gallon, which means the Rover costs more $80 to fill up. The average monthly salary at ASOS is $200.

Before the bikes came, the doctors hiked to the villages — one day in, one day treating people, one day out. They did basically the same thing they do now — provide vaccinations, basic medical care and education about sanitation and family planning — but not as often. Or as well. Some medicines that couldn’t be kept cold for three days can be surrounded with ice and stuffed in a backpack for half a day.

The program began in ’95, when the World Wildlife Fund began working with villages near the Andohahela Nature Reserve, a parcel of protected land that guidebooks call Madagascar’s Yellowstone. To gain tribal cooperation with conservation — no burning — the WWF promised health care and tapped yet another U.S. Organization called STARFISH for medical supplies, and the bikes to get them to people.

It’s a noble, complicated program but the ASOS doctors — Madagascar born and educated — mostly care about helping people. “Man is the first thing to conserve,” says Dr. Harinesy Rajeriharindranto, the director of ASOS. “We are a natural resource.”

Harinesy is sitting in the ASOS clinic in Tolognaro. He isn’t riding because he broke his arm and leg in an off-road motorcycle wreck. His casts are heavy, ‘70s-style plasters. With 20,000 inhabitants, seaside Tolognaro is Madagascar’s second-largest city, but it would be called a city only in Madagascar. There might be five paved roads. The housing along the sandy lanes is as dense as a New York City block, but with one-story wood-and-thatch shacks instead of brownstones, with water available out in the street from spigots. Four-passenger taxi-brousses — bush taxis — wobble along at 5-15 mph, stuffed with 10, 12, 15 people plus panicked chickens and squiggling baskets of fresh shrimp. The city smells of ocean air, human feces and the charcoal used to cook each meal.

The ASOS clinic is a desk, an exam table and a back room with a table and cot. Wooden shutters that close over the windows and doors at night lie open during the day. Flies buzz around. Emaciated dogs slink through. A box of bike tools sits in the back corner: a ring of hex wrenches, a crescent wrench, a hammer, a screwdriver, pliers, a spoke wrench and three mostly dried tubes of patch glue.

Behind the clinic, a volunteer mechanic named Gasp squats in the dust, lubing a Specialized Hardrock with motor oil. The bikes are kept going however they can be. They’re essential. Since the doctors began riding, Harinesy explains, they’ve not only increased their range but their effectiveness. For instance, 15 percent of women in ASOS territory now use birth control — almost double the number achieved by bigger, national programs. Similar success with diseases and nutrition also appear to be gaining critical mass, although two years is too soon to gauge long-term effectiveness.

Harinesy watches as Dr. Heron Rakotovelo treats a woman for malaria, parasites, diarrhea and gonorrhea. The cost; 1,200 Malagasy francs. About 23 cents. Earlier, a husband had paid for care of his wife’s infected thumb with a chicken he carried upside-down by the legs.

“That is not our real cost,” explains Harinesy. “It is a symbol.”

It is a symbol.

---

Dr. Heron is medium height, slight, wears glasses and is as graceful and smooth on a bike as if he rode for fun instead of lifesaving. He writes poetry about what he sees in the villages, but can’t fit exact translations or even the emotion into his broken English. We can only guess.

One poem might be about the dirt road he rides on now. To his left is the crunchy beginning of what’s known as the Spiny Forest, a desert land of slender, 30-foot-tall thorn trees and thick, squiggly cactus unlike anything you’ve ever seen. Dr. Seuss meets Freddy Krueger. To his right is the edge of the rainforest, a mountain range that holds back the clouds full of water. He rides this strange rolling, red-dirt border under a 95-degree sun.

Or his poem might be not about the dirt road but the bikes he uses to ride it — a bike someone in America no longer needed, not because it was broken or old but simply because it was not new. If someone could explain the mountain biker’s hysteria for the hip and the fresh to Dr. Heron in a way he could understand, he might try to write about that.

Another poem might be about crossing the Ifahoo River on the way to the village of Tsimelahy, about people bathing there, pounding laundry against rocks, and the sound of kids laughing and splashing through the water, and the sound of water flowing against rock, and how even with all of those sounds you could hear the footsteps of a woman shushing against the sand. And he might even compare the symphony to the sound of a modern laundromat in the United States and ask which is really better.

A poem about the chief of Tsimelahy. He wore tan pants, a faded blue polo and a digital watch with a blue face — perhaps a kid’s sports watch. He lit his hut with a light bulb turned upside down and filled with burning oil. For all the Western influence, the chief was more authentically tribal than all the traditionally costumed dancers in theme shows in countries affluent enough to cater to tourists.

And a poem about stomach worms, of course, and all the other recurring parasites and illnesses you can’t cure and wish you could but would only be wasting money and time and medicine if you tried. About education being more valuable than treatment in a cruel way. About just trying to get the villagers to keep their nails short so dirt won’t accumulate there to make a home for parasites waiting to get into the food. How medical intervention in Madagascar is not a fight against spectacular accidents but against the slow wearing down of humans. Less about denying death than relieving misery.

Maybe he will write a poem. Maybe he is writing a poem. He is riding a mountain bike.

_______________________

Originally published Mountain Bike magazine, November 1998