In a corner of Galmi Hospital's walled compound, a group of malnourished children play in the dirt while their mothers wash, cook and talk.
The hospital runs a center where doctors treat children and teach mothers how to make nutritious food. This summer the center overflowed its capacity and one or two women often had to sleep on the floor in each of the two-bed clay rooms provided for their two-week stay.
Yakoubou Sanoussi, a 43-year-old Nigerien, is Galmi's chief surgeon. He has been working at the hospital for 10 years. He studied in Europe and has worked elsewhere, but he came back to Galmi Hospital because of its good reputation in Niger.
"This is a place where people find comfort," Sanoussi said. "I love my country. I've been even to France to study, but I didn't feel I should live there because here they need me more than anywhere."
The people do need Sanoussi and other medical help.
The 15-bed center is typically filled to capacity with about 20 children and parents. Last July, 45 children packed the courtyard.
While children eat nutritional food packets and doctors monitor weight gain, women learn they can add things like sugar and oil to traditional millet porridge to keep their children healthier.
Fewer than five percent of children treated at the center come back with repeat malnutrition problems, said Dennis Schellhase, an American pediatrician at the missionary hospital in southern Niger.
Before they show up in this corner of the hospital grounds, children are screened through the outpatient clinic in the hospital, a building from the 1950s with sporadic electricity and few other amenities. The doctors here quickly learn that what would be simple procedures in the United States can be much more time-consuming when equipment is old or broken, rooms are filled to capacity and doctors scarce.
Some malnutrition patients who end up at Galmi are referred from local village clinics like the one staffed by World Vision near Dakoro in East Niger. Here, hundreds of women travel miles, often on foot, so their infants can be weighed and measured to determine if they need treatment for malnourishment.
Niger, a West African country just north of Nigeria, ranked lowest of all the world's countries on the 2009 United Nations Human Development Index, a ranking that combines life expectancy, education, and income. In years like this one, meager rainfall leads to a low harvest and severe food shortage. More than half of the country's 14 million inhabitants went hungry because of a poor harvest in 2009. Food is always lacking a few months before the harvest, and Schellhase often sees malnutrition combined with other problems like typhoid or gastroenteritis.
Doctors and staff workers here at Galmi learn early what local residents have known for centuries: not to give up in the face of hardship. Schellhase, 52, has been in Niger for just over a year and said he's already seen more deaths here than he had seen in more than 20 years as a pediatric pulmonologist in the U.S. His first patient died less than a week after he started work.
"I was making rounds with a medical student from the United States, and we stopped in A ward. The first bed in A ward—it was like the third patient I'd seen—wasn't breathing. And his mother didn't realize he wasn't breathing," he said.
"If you can't breathe here, you don't survive. So he died. Yet I was just at the start of rounds. They were all watching; I had all of A ward to see, and patients over on B ward. So, there's no time to mourn. You just keep going."