The "Biraul Block" (Darbhanga District, Bihar State, India) has a population of about 300,000 people, many of whom are not wealthy. Biraul town centre is bustling to say the least.

The "Biraul Block" (Darbhanga District, Bihar State, India) has a population of about 300,000 people, many of whom are not wealthy. Biraul town centre is bustling to say the least. It's a bit like someone has siphoned off a couple of lanes of the M25 to run through the middle of Oxford Street, sucked out every last iota of material wealth, then finally added a large number of agricultural vehicles and domestic animals for decoration. The smell is dominated by sulphur, smoke and... stool. The MSF ex-pat house is located on the outskirts of the town, suburbia if you will, but even here the concept of noise-pollution is but a twinkle in the eye of the local kill-joy. The default state of the lorry klaxons, day or night, is set to "on". Occasionally, if there are no other vehicles or people or cows or goats in sight, a driver may desist from using it for a passing moment. This overnight cacophony is a small challenge.

On arrival, I had a very strong sense of familiarity from the area. Presently I realised that this was because it is very flat, very fertile and very wet, reminding me strongly of the fens of East Anglia. Here the similarity ends though, Norfolk being about 20 degrees colder and about 80 times richer than Biraul. It is this humid, still heat that presents a bit more of a challenge. Giving up any hope of ever being free from perspiration again, I take the only sensible way out and decide to take up sweating as a hobby.

The other MSF ex-pats have had some time to get use to these things. They have been through quite a lot together over the last six months, and my new colleagues are close knit like siblings. I have initial concerns that the social group is going to be about as easy to crack as the average Brazil nut is with the average plastic coffee spoon. But they are special people (in the flattering sense) and they give me enough openings to fumble my way into the dynamic. The outgoing doctor, an animated Greek girl of exceedingly good nature, shows me the ropes at work. She seems so good at her job and good with her staff... how am I going to get to where she is now in six short months? She tells me what I suspect is a white lie:

"You'll be fine."

That said, I pick up the bare bones of the clinical care, a nuanced blend of nutrition and paediatrics, fairly quickly. The staff management is clearly going to take a lot longer to get a grip on, psychology being more complicated than physiology and all.

Given it is diarrhoea season, the number of patients in the stabilisation centre is low during my first week. About seven of the sixteen beds are occupied, depending on the day. The malnourished kids we are treating are aged between six months and five years. Some of the sicker ones have drips or nasogastric tubes hanging out of their emaciated bodies. They sit or lie on their beds, looking understandably miserable. The time between them starting to smile and being discharged is brief by necessity – every extra day is another chance to pick up a hospital-acquired infection. Next to the children sit their mothers in their colourful saris, eyeing the goings on with a certain suspicious resilience.

It's not easy being a Mum in Biraul. Juggling the childcare, domestic work and agricultural labour, often while pregnant, is no mean feat. There is tremendous pressure on a mother’s time, and sometimes impossible decisions have to be made.

Her malnourished child becomes sick, for example. Does she stay with her child in our stabilisation centre, sacrificing irreplaceable harvest days and the care of her other children? Or does she continue her (literally) vital roles at home and hope her child gets better? If you were to forget that the decision was impossible to begin with, you might judge her decision either way harshly. It is perhaps one of the reasons that previously we were seeing the phrase "careless mother" written in the medical notes. MSF have since worked hard to change this mentality among the staff. I ask our head doctor, my right hand (and probably my left hand too for the first few weeks at least), about careless mothers.

"There's no such thing," he says, quick as a shot. No flies on this doctor. The same cannot be said of Biraul, unfortunately.

The day after I arrive in Biraul, a child on the ward dies, ravaged by kala azar (or visceral leishmaniasis) which is even more unpleasant than it sounds. Horrible as it is, it does not kill as many each year as malaria or diarrhoea, and has slipped quietly into the category of a neglected disease. The people who suffer from it are generally poor, and drug companies have little incentive to develop new treatments (many of the drugs currently available have severe side effects - you would think long and hard before giving them to your dog). Since July 2007, MSF’s other project in Bihar State has treated over 10,000 patients with this killer disease, as well as trying to raise awareness in local communities about it. Tragically, this one poor four-year-old didn’t quite get to us in time to be saved.

By the end of my first week, several other sick children have been taken from the ward against medical advice, by parents (who are definitely not careless) having to take a calculated risk on the health of one child such that they can avoid running out of food for the whole family. At night, it is still as noisy as an illegal rave (and twice as sweaty) but my sleep is much better. It somehow seems childish to let little things like this bother you. There are bigger challenges to think about in Biraul.

Women working the fields in Biraul © Luke Chapman/MSF

This post was first published in Spanish in