**Its serious for children here, says Bernadette Ammaji, 37, as she prepares food at** **Mdecins Sans Frontires/Doctors Without Borders \(MSF\)'s** **therapeutic feeding centre in Bokoro town, central Chad.** Some mums dont have the means to be able to feed their children. Others do, but they fail to take proper care of them due to a lack of education about hygiene and nutrition. You need to be strong and brave to care for a child here. Its not easy.

Bernadette, who has worked with MSF since 2012, is one of more than 200 staff working to tackle malnutrition in the region. Malnutrition is endemic in Bokoro, as it is across much of Chad, with almost half of child deaths in the country associated with the condition. Bokoro region lies around 300 kilometres east of Chads capital, Ndjamena, towards the centre of this landlocked central African country. Its a relatively stable part of the country, but also neglected, usually out of the headlines due to Boko Harams creeping presence in the northwest of Chad.

This year, in villages across the Bokoro region, in partnership with the Ministry of Health \(MoH\), MSF is running 15 mobile outpatient clinics for malnourished children aged between six months and five years old. In Bokoro town, MSF has an Inpatient Therapeutic Feeding Centre in an MoH Hospital with an intensive care unit where the sickest children are referred. And for the first time, MSF is also working in the area to identify and try to prevent children at risk of malnutrition from falling ill.

OUR PATIENTS

**Hawa Haroum, 40, from Tchaway village in Bokoro, Chad** _Hawa Haroum is from a small village in central Chad. She shares her home with her husband, their children and her husbands mother._ _She has been in MSFs intensive care unit in Bokoro town for four days, looking after her grandson, Adeen, who is two years old. She says it feels very far from home. She explains that she is at the hospital instead of the childs mother, Fatima, who is at home having just given birth to her second child._

Fatima couldnt leave the house, so I took Adeen to the clinic to pick up some rations \[enriched peanut paste to treat malnutrition\] and then return home, but when the nurses saw Adeen, they said I had to come straight here. I thought I was just going to the mobile clinic and then going home again, so I wasnt very happy when they told me this. Id been going with Adeen to the mobile clinic for three weeks but this time they said he wasnt getting better and that he had to be transferred. Ive had to leave my mother\-in\-law in our village shes a very old woman. I also have a three\-year\-old child and Ive had to leave them both. I didnt even have the chance to get a change of clothes. I asked but they said it was too far for me to go and they couldnt wait. There were four other women and their babies on that day who were transferred to the hospital here from Tchaway. One woman was lucky: she called her husband, who cancelled what he was doing and came on a motorbike to deliver her things before we left. Adeen had a fever, he was vomiting and had diarrhoea. But since hes been here, hes been okay. Theyve given Adeen medicine and a lot of milk. Theyre always checking on him. Ive had a lot of good food. The baby hasnt put on any weight but I can tell his health is better. I hope he continues to get better like this over the next couple of days." **Zara Abba, 32, from Ndjamena, Chad** _Zara Abba has been at MSFs intensive care unit in Bokoro town for four days, caring for her granddaughter, Katalma Moussa, who is two years old. Zara Abba was visiting Bokoro to pay her respects to a family member who'd died when her granddaughter fell ill._

She hadnt put much weight on for a while and then she started to get very liquid diarrhoea and her health got even worse. I had been taking her out for walks and to play with the other children, but since she started getting diarrhoea, she didnt have any energy and I couldnt do that anymore. She was always hungry and crying and it was like the milk we were giving her wasnt enough. I looked after her for seven days at home but after that knew I had to get her to a clinic.

> I would travel all the way to France for my children's health

As soon as we arrived at 5 pm a doctor examined her. He gave her some water and an injection. Since then she has only had diarrhoea once and now shes almost back to normal. She is starting to get her appetite back. Its as if she cant eat enough. She finishes all of the milk they give her and then she cries because she wants more. I would travel all the way to France for my childrens health. So I have no problems staying here until Katalma gets better. Yes its hot and noisy, but its hot and noisy in my house too. I have given birth to 15 children. Seven of them have died and eight are still living. Two of them were twins and they died on the same day they were born. The others, I dont know why, it was Gods choice. My husband is a Marabout \[Islamic religious leader\] and also sells things at the market in Ndjamena. Four of my children are married and the other four still live with me. All of them have gone to school and I hope they can achieve something with their lives. This is my daughters first child. Shes still in Ndjamena but Ive been speaking to her every day. She calls to ask about the health of her daughter. I say, your daughter is getting better, and MSF have gone above and beyond to help your daughter. Theyve worked really hard. I would really encourage MSF to keep putting in so much effort for these children. There are a lot of illnesses for children here, but thanks to MSF there are now a lot of nurses and, even if there is still a lot of illness, its getting less.

EXTREME CLIMATE AND HARMFUL TRADITIONS: A DEADLY COMBINATION

**Bokoros climate is harsh. It reaches 45 degrees Celsius and has a very short rainy season.** Living conditions are really hard here, says Suzanne Moher, 36, a Spanish epidemiologist with MSF in Bokoro. Yes, its green now, but when I arrived here a couple of months ago there was no sign of life.

The population has just a couple of months to grow and harvest enough crops, usually millet, to last them the year. The vast majority of people in the area are subsistence farmers, so a bad harvest can be devastating. At the moment, hundreds of women bring their babies to MSFs mobile outpatient clinics everyday, as the number of children with malnutrition reaches its annual peak. Families havent yet collected this years harvest, but last year the harvest was bad and some people have run out of food. Last month, MSF transferred an average of 50 babies every week from the outpatient clinics to its intensive care unit in Bokoro for emergency care.

Babies and young children in Bokoro also fall into malnutrition due to cultural practices that can unintentionally cause more harm than good. Some mums here say that when their next child is conceived, their breast milk is not good for their existing child, says Benedicte La\-Toumbayle, 28, a Chadian nurse at MSFs therapeutic feeding centre in Bokoro town. They think that by continuing to feed their baby breast milk, they will harm the future child in their womb. Mothers often prefer to take their sick child to a religious leader rather than a health clinic. Marabout \[Islamic religious leaders\] may say Koranic prayers for the baby, give them a plant\-based concoction which can be poisonous, make three cuts on a babys stomach or cut out their uvula, at the back of the throat.

In the best cases, this can delay malnourished babies getting the treatment they need and, in the worst cases, vulnerable babies, whose immune systems have been weakened by a lack of food, can die from poison or infection. It doesnt help that making the journey to public health clinics in Chad can be expensive , the clinics often dont have the necessary medicines or enough trained staff, and despite a national free care policy for malnourished children there are often other hidden costs that make it impossible for people in this area to afford this essential care. Sadly a child died today, says Benedicte. At home they had given him something to eat as part of a traditional medicine procedure which had poisoned him. When the child arrived here at the clinic we did everything we could. Its miserable to see so many children suffering in front of you, but its also this that motivates me to keep going and to help them.

THE MSF TEAM

**Andrea Kuehn, 30, from Vancouver, Canada. Andrea is an outreach nurse at MSFs mobile malnutrition clinics across the region of Bokoro.**

"I arrived in Bokoro, Chad three months ago. Its my first mission with MSF and I was so excited to finally get here. I am responsible for the 15 mobile malnutrition clinics we are running in 15 different villages. I oversee the team of nurses, registrars and pharmacists and make sure everything's running smoothly. One day I was at one of our mobile clinics and a mother brought in a six\-month\-old baby girl. The baby had been sick for some time with fever and a cough and she was having difficulty breathing. Her parents had first taken her to a traditional healer.

> I remember sitting in the vehicle and just praying that this child would make it. It was the longest 45 minutes of my life.

In an attempt to heal her, the healer had cut out the uvula at the back of the babys throat and theyd also cut lines into her chest. So the poor child was of course in pain and was refusing to breastfeed. Infection was setting in. By the time she arrived at the MSF clinic she was tiny, very dehydrated and the infection had spread to her entire body. You could see that her whole body was having to work very hard to make each breath. We needed to transfer the child immediately to MSFs intensive care unit in Bokoro town. I remember sitting in the vehicle and just praying that this child would make it. It was the longest 45 minutes of my life. With every breath the child took I didnt know if it would be her last. Thankfully this child did make it to the hospital and a few days later I went to visit her and her mum. The child was no longer in intensive care. It was so good to see her improving and gaining weight. **Benedicte La\-Toumbayle, 28, from Bokoro, Chad. Benedicte is a nurse at MSFs therapeutic feeding centre and intensive care unit in Bokoro town, Chad.**

I started working with MSF four and a half years ago. As a Chadian I saw what my people were going through and MSFs principles of helping people in distress really resonated with me. Im very happy that I get to help my people. I arrive early in the mornings and check all of the childrens vital signs. We do this every hour as many of the children in the therapeutic feeding centre are very ill, and for the really ill ones we check on them every 10 to 15 minutes.

> I have a daughter of my own who is 19 months old. Shes healthy but it can be difficult seeing children the same age that are so ill

From the moment I get here Im really busy. I arrive at 7.30 every morning and, apart from a short break for lunch, I dont stop until 5.30 pm. If you waste any time, this can have terrible consequences for the health of the children. A malnourished child that isnt well can fall into death very quickly. The only thing I can say to the mum is that the reason your child died is because of what you gave it to eat. And sometimes the mums tell us that their other children went through the same traditional procedure and theyre also ill at home. Then we have to go and find the other children straight away and bring them to the hospital too. I have a daughter of my own who is 19 months old. Shes healthy but it can be difficult seeing children the same age that are so ill. I want my daughter to exceed me. Im a nurse but I think with the right support and strength she can do even better than that. I think everything MSF has done for malnourished children here is amazing. There isnt a health centre in Chad that would be able to take responsibility for all these ill children. They dont have the expertise or resources. Its not an easy job."

PREVENTION THROUGH EDUCATION

**Unfortunately, there is a widespread lack of understanding across Bokoro about nutrition.** Instead of breast milk, mums sometimes feed their babies goats milk or bouille \[a type of broth often made from millet\], or other adult food like this, and then the child gets diarrhoea and falls into malnutrition, says Benedicte La\-Toumbayle. Education rates are low with a national literacy rate of just 33 percent and most of the mothers we see here havent spent a day at school. Many dont understand what it is thats making their children ill. A short lesson on hygiene and nutrition is a core part of each mothers visit to either our outpatient clinic or intensive care unit. MSF has launched an emergency response to malnutrition in Bokoro at this time of year four times in the last five years. Over that time, it has become more clear that these arent one\-off emergencies, but part of a pattern of recurring malnutrition with complex, interconnected causes.

As a result, this year we started work in Bokoro before the malnutrition cases peaked at the start of the rainy season \(May to October\), setting up our outpatient clinics in January instead of July. Since then, we have treated more than 9,140 babies and children for severe malnutrition. This year MSF has also set up a component to the project that works to prevent babies and young children from getting malnourished in the first place. The children who come to our distribution sites should be healthy, but are at risk of getting malnourished, says Elizair Djamba, supervisor of MSFs distribution team in Bokoro. For the first time in Bokoro this year, were giving these children rations of specially formulated supplementary food and giving them a chance to stay healthy.

The MSF teams have distributed ready\-to\-use supplementary food, as well as mosquito nets and soap, to more than 30,000 mothers across Bokoro, along with a short health and nutrition lesson. The work is hard but staff feel passionately that its what is needed if MSF is to make an impact on recurring malnutrition. We often arrive at the distribution site as it starts pouring with rain, says Elizair. "But we have to be out in the rain with the women, showing them that its important to be here, that its worthwhile.

_To find out more about our work in Chad, visit [https://www.msf-me.org/chad](https://www.msf-me.org/country\-region/chad)_