Fieldset
A very curly creature

The humidity here is through the roof.  My hair is….a creature.  A very curly creature.  There are goats out my window, and kids playing soccer in a tin can and remains of buildings strewn next door.

The humidity here is through the roof.  My hair is….a creature.  A very curly creature.  There are goats out my window, and kids playing soccer in a tin can and remains of buildings strewn next door. A group of young men sit in a circle on upended dried milk cans, chatting in the shade of a tree.  An hour ago everyone was napping.  You have to.  People keep telling me that the hot season hasn’t arrived yet.  Awesome.

I and two-thirds of the approximately 700,000 people in this country live in Djibouti City.  The rest of the population are nomads who roam the hinterlands and eke out a subsistence.

Why is MSF here? UNICEF and the Djiboutian government realized in 2008 that there was a nutritional emergency in Djibouti City and put out the call for help.  In response, MSF came and set about opening up a program to treat severe malnutrition in kids aged from 6-59 months.  Basically, because Djibouti City is such a transport hub, everyone comes here on their way to somewhere else, and usually lives in very precarious circumstances during their stay.  There are Somali and Ethiopian refugees who are on their way to Yemen and Saudi Arabia, and nomads who come to town, often because life has been too hard for them outside of it.

So.  Malnutrition.  What do we do about it? We run a paediatric malnutrition program set in the slums around Djibouti City. Our patients are about 50-50 locals and immigrants or refugees.

First, there is a group of local community workers who go door to door in the slums to find malnourished kids.  They then refer these kids to one of the six ambulatory care centres, which are scattered throughout those neighbourhoods and which are run in conjunction with the government.  There, the kids are seen once a week, weighed, screened for disease, and given a week’s ration of lentils, rice, oil, and….the famous little pouches of micronutrient-enhanced peanutty-milky-goodness. This humble paste, much like a sweet peanut butter, has basically revolutionised the treatment of malnutrition by providing an alternative to the nutritional milks that need to be prepared carefully under semi-sterile conditions.  So whereas nutritional programs used to have massive wards and require long stays in hospital, we can now manage a lot of kids in the community.

But, some of the kids do get sicker. Those are the ones who get referred to where I work, the CNTH or Centre Nutritionnel Thérapeutique Hospitalière, the centre of soins intensifs--the intensive care unit (ICU).

Wait a second, you might be saying…I thought MSF worked in the bush.  What are you doing in the city?  It turns out we’re kind of a pilot project.  Worldwide, the movement of people from rural life to urban centres is flooding cities and creating massive slums, like Balbala, the one we work in.  Living conditions are so horrible that they are approaching the life-threatening conditions previously only seen in rural regions during times of disastrous harvest, or in war-torn contexts.  MSF, with its mandate to respond to emergencies, is beginning to expand that to include urgent urban situations.  So it is trying to figure out how to do bush medicine in the middle of the city.

I’ll be trying to figure that out too.