The first patient

The wind is blowing from the sea, as it usually does here in southern Madagascar. The landscape here is billowing like the swell in the ocean after a big storm.

The wind is blowing from the sea, as it usually does here in southern Madagascar. The landscape here is billowing like the swell in the ocean after a big storm.

From a hill one can see the mountains of Andohahela. But everything here is very dry. The winds are often strong and today is no exception. One would think that the winds from the ocean would carry rain to the shore, but the sky is as clear today as any other day this week. Some days, cumulus clouds tower up in the afternoon, but no rain has fallen since I came here.

We go with our mobile team of doctors, nurses and local staff to measure and record the children's arm circumference, their height and weight, and to distribute packets of enriched peanut paste and medicines. We also have a number of people who will work in the villages to provide information about health, hygiene and nutrition.

Today we go to the small village of Maroalimpoty situated on a slight slope down towards the Indian Ocean. This is where women come once a week to get the packages of peanut paste for their most emaciated children. Some have walked up to 24 km today on the sandy paths to get here.

When we arrive, many people are already waiting in the shade next to some bushes. The dry wind sweeps through the waiting area. A little girl, no more than one metre tall, is carrying around her malnourished brother who has just been registered in our programme. She is 13 years old and probably this short from not having had enough nutrition during her early years to grow normally.

I sit with the nurse who works in Maralopoty and we examine the most emaciated children. The seventh patient of the day is a little girl who is somewhere between 10 and 12 months old (most mothers here do not know exactly how old their children are). The little girl is skinny. Her upper arm circumference is 86 mm (severe acute malnutrition is anything below 115 mm). She weighs 3.7 kg.

She was admitted to one of the few beds for treatment of acute malnutrition at the hospital in Ambovombe, the closest major town, about six weeks ago. When she was discharged from there she weighed 4.6 kg, but since then she has lost 900 g. Her grandmother died of tuberculosis a few months ago.

Perhaps that is why she is malnourished, because she has been infected and her body is devoting so much energy to fighting the infection. A third of the world's population carry tuberculosis. And tuberculosis is common here in Madagascar. She also has a disability, maybe Down’s Syndrome.

The girl is very tired. When I examine her, she doesn’t even yell. When I put the stethoscope on her chest, her big eyes just look at me. The stethoscope diaphragm covers the entire left side of her chest. It is difficult to get good contact with the straight membrane on a breast without subcutaneous fat. I can count all the ribs with my eyes. Inside, her little heart is ticking at 160 beats per minute. It's too fast, and is a sign of dehydration. The girl has had diarrhoea for the past three days. Her little body does not have many reserves. I decide to admit her to our intensive care unit, which opens today.

In the ambulance, she deteriorates. She gets more tired and has a fever. When she arrives at our unit, she has a rash on the abdomen which I suspect is due to a bacterial infection. She becomes the first patient in our intensive care unit. Here everything is ready: doctor, nurse, 20 beds, enriched milk, antibiotics, special rehydration solution for malnourished patients.

Welcome, little girl. We are here for you.