"It is hard to see a child dying, even for the experienced medical personnel. In the beginning it happened almost every day because we were receiving many children who would have needed treatment much earlier. Via widespread screening by our mobile teams we are meanwhile able to identify and treat problematic cases at a much earlier stage. But still, some two year old kids weigh just under three kilos, which is less than what a European baby weighs at birth.

MSF: What is the situation like in Borno state?

Ton Koene: "Our teams screened more than 2,500 children in different villages of southern Borno state and found out that between one and two percent of them were suffering from severe acute malnutrition. This means that the child's weight falls below 70 percent of what is normal. This is quite alarming and particularly unacceptable in conflict-free Borno state.

"In the area where we work right now we expect up to 900 severely malnourished children who might die if they don't get medical and nutritional support. And this number only represents a small part of Borno state."

Why are so many children undernourished?

"The reasons are manifold. There are several chronic factors such as a poor feeding practice by mainly young mothers who stop breastfeeding too early and are unable to give their babies a healthy, varied diet.

"Chronic food insecurity is another problem that not only affects Northern Nigeria but a sub-saharan zone spanning from Mauretania via Niger and Sudan to Ethiopia. Food stocks are depleted because rains have been patchy for years and last year locust swarms devastated many crops. And the next harvest is only due to start in November.

"While children were already weak due to the food gap, bad diet and poverty, a measles epidemic aggravated the situation at the beginning of this year. Already vulnerable children were hit extra hard. As a consequence, we can see a relatively high level of severe acute malnutrition among those under five years of age."

What is MSF doing to address the problem?

"MSF has set up a therapeutic, or intensive-care, feeding centre (TFC), in Biu hospital, the main referral hospital of the region. The building can accommodate 50 to 60 children. Additional tents have been put up in the hospital compound to eventually increase the feeding centre capacity to up to 100 children.

"At first, staff members weigh and measure children to get a more accurate idea of their condition. They then receive up to eight meals of special high-protein milk around the clock until they have gained enough weight to be released.

"At times, the little ones are so weak that they no longer even have the strength to swallow. In such cases, they have to be fed through a tube to their stomach or put on a drip. The problem is that people are very dispersed in the district and do not necessarily know about our services. That is why we send a mobile outreach team to main villages.

"Together with local authorities, MSF staff invite all children under five years old to gather on the village square or under a big tree, identify the most severely malnourished by measuring them and take them, with the mother, to the feeding centre in Biu."

What is the atmosphere like in a feeding centre?

"The building and the additional tents are quite crowed. Somewhere there are always some babies crying, mothers are busy with feeding them, staff is running around doing check-ups or handing out the special milk formula.

"It is hard to see a child dying, even for the experienced medical personnel. In the beginning it happened almost every day because we were receiving many children who would have needed treatment much earlier. Via widespread screening by our mobile teams we are meanwhile able to identify and treat problematic cases at a much earlier stage. But still, some two year old kids weigh just under three kilos, which is less than what a European baby weighs at birth.

"They are apathetic, have wrinkled faces and their skin resembles parchment paper. There's a lot of sadness in a feeding centre. You see women who have to go back home with the body of their dead child. But there is also a lot of relief and happiness when you see that children are improving, that they are out of life danger and gaining weight. So amidst all the bustling activity there are very strong positive and negative emotions."

How long do the children have to stay in the therapeutic feeding centre?

"Normally, the mother and her child should stay up to six weeks in order to complete the treatment. However, a lot of mothers and children leave after one or two weeks. The women feel pressured to go back home for many reasons. At the moment it is planting season, so they are needed in the fields. Back home they have other children to take care of.

"Finally, in predominantly Muslim northern Nigeria, where men usually have several wives, a women who is leaving home for several weeks will lose social status within her family. The only thing we can do is to explain to the women and their husbands how important it is to finish the treatment.

"We have also adapted our services to the women's constraints: As soon as the children have passed through the most critical period in the feeding centre, mothers can take them home. They will then come back on a weekly basis to certain main villages, where our teams provide ambulatory medical follow-up and therapeutic food rations."

The project is intended to run until the end of this year. Why is the intervention limited in time?

"MSF cannot address the chronic aspects of malnutrition. To solve those MSF would have to deal with deeply rooted social and cultural aspects and would have to get involved into developmental aspects such as agricultural schemes, long term education, etc. This is not our role as an emergency oriented agency.

"MSF focuses on life saving medical activities during periods when people are even more affected than usually. We hope that with measles complications fading away and the new crop being harvested, mortality among children will be back to normal levels by the end of this year. We can then hand our services over to the local hospital and support it with medical and nutritional supplies for a certain time.

"In this way, our team can move on to other emergency situations where people are in even more dire need of support."