Letter from the field: Satisfactions and sadness in Niger's intensive care malnutrition centres

“I work with MSF in an intensive care malnutrition centre (Centre de réhabilitation nutritionnel intensif - CRENI) in Zinder in southern Niger. Here, we look after up to 400 severely malnourished children who have medical complications. I arrived in July, just before the start of the annual peak in malnutrition, which we waited for and expected, but nevertheless took us by surprise. In Niger in June, 2010, nearly 17 percent of children under-five were found to be acutely malnourished. Of the children in the most vulnerable group - six to 23 months - more than a quarter were acutely malnourished.

“My day begins with a 25 minute walk to the CRENI. This daily interaction with people on the streets is very pleasant, and shares a different dimension to peoples’ lives.

“The CRENI consists of a number of permanent tents made of plastic sheeting, organised into different phases of re-nutrition. During the peak, the blaring sun and the plastic sheeting of the tents mean the temperature inside reaches well over 40 degrees. It’s difficult. During the ward round I run to emergency admissions and reassess children that are medically unstable in ‘cote rouge’ - the red zone - for severely unwell children. It is overwhelming to cope with not just the severity of illness but the rate at which it presents. I often feel torn into many small pieces when trying to assess and treat many children at once.

“With a lower number of children in the CRENI since the beginning of the year, we are now focusing on tutorials for the local nurses, to share new skills and better understanding. My placement ends in April and my aim now is to try to empower the nursing staff through education, in the hope that this useful piece of me will stay here after I leave.

“During the peak of the hunger season, children, of course, battle malnutrition, but the peak also falls during the rainy season and during the rainy season malaria is an unforgiving disease. Almost all the malnourished children we see have malaria. Respiratory tract infections, skin infections and gastroenteritis are the other common problems we see that can be life-threatening to a malnourished child. When I compare the malnourished population here to kids back home, the most alarming difference is the degree of severity. Gastroenteritis back home is unpleasant, but almost never life-threatening; here diarrhoea can quickly take the life of a child if they are not treated early and adequately.   

“I ask for stories, in an attempt to understand why children in this particular place don’t have the same chance to survive. It is difficult to understand and I am still searching. It is disturbing to observe mothers in the CRENI; when their child dies there is very little expressed mourning. It is troubling and heartbreaking to see how normal the loss appears. It is not uncommon for a child in the CRENI to be the last surviving child in a family where there were once seven or eight. When death becomes routine it is frightening to imagine what these families have been through.   

“There is sadness but there is also a satisfaction in my work that I never tire of feeling. I work mainly in the acute intensive care area, which children will be admitted to if they are in need of vigilant medical observation and attention. Once he or she stabilises they will then move through the phases, which focus more on calorie intake and weight gain.

“I get a thrill out of walking across to Phase II - the final phase before the discharge home - to see the progression of the children, especially those that have had a long journey to recovery. Sometimes I don’t recognise them, and it is only by recognising the mothers that I then know the child. It is a pleasure when this happens; the success stories are really special.

“I feel that here we admit old people and discharge young children. The lack of cheek muscles and thus prominence of cheekbones in a severely malnourished child robs them of their innocent face.

“Every child should have the chance to be nourished with a diet that allows him or her to survive past the age of five, a diet adequate to supply them with energy for brain development, physical growth, and a capable immune system. Just as importantly, every child should have the opportunity to have a diet that allows them to play, allows them to just be a child.”