It’s the silent ones that you notice. In an outpatient’s department (OPD) full of people and screaming children you notice the ones that are quiet. It might mean something’s seriously wrong. The hospital is seriously swamped after we start our nutrition screening in the camp. All of our teams are referring children based on MUAC (mid-upper arm circumference). MSF has created special bracelets, colour-coded green (for safe), yellow (for pay attention), orange (for moderately malnourished) and red (for severely malnourished). Anybody can be trained to wrap this bracelet round the arm of a child and assess the severity of malnutrition.

A red mid upper arm circumference measurement indicates that a child is severely malnourished Photo © Ruby Siddiqui/MSF

And our outreach teams have been finding a lot of malnourished children. The OPD has become a sea of children’s faces, each carrying a white outreach referral slip. The hospital staff are blaming me. But I know they’re just as pleased as me that we’re identifying these kids before they’re beyond medical care. And our outreach workers are enjoying helping kids to live rather than asking families about who died.

But as I wander around OPD, tears come to my eyes. I have never seen children this skinny and weak. Imagine an upper arm, so far in the red zone that it’s basically just a bone, wrapped in skin. It’s heartbreaking to see children suffering this way, a shadow of their former selves, unable to muster a smile. And on top of that some of them are hot to the touch or incredibly dehydrated. Malnutrition makes the child more susceptible to infections such as respiratory tract infections or diarrhoeal diseases (that can lead to dehydration). How much more can a child take?

So we have to be super-vigilant in triage and pay particular attention to those kids that are not responding. And it’s such a relief to hear a child cry. It means they’ve still got some fight left in them.