Northwest Nigeria is in the grip of a malnutrition crisis caused by a deadly combination of factors: people displaced from their homes by violence, environmental change, years of poor harvests, soaring food prices and an economic crisis. In response, Doctors Without Borders/ Médecins Sans Frontières (MSF) is running its largest-ever malnutrition project in Katsina state.

When one little boy, Musa*, arrives at the MSF malnutrition treatment centre in Katsina, the team hopes to be able to stabilize him quickly. But things are more complicated than they seem.

There are several signs that a child has severe acute malnutrition, and Musa had all of them.

I’m part of the MSF team in Katsina, in northwest Nigeria. Malnutrition is a year- round problem here. But it is worst in late spring and summer when the food from the last harvest begins to run out and the “lean season” begins.

On top of this, we live in an area that is regularly hit by armed conflict and insecurity. This makes it difficult for people to farm their land, and means that vaccinations for diseases associated with malnutrition, like measles, often don’t happen.

The combination of these factors is devastating: last year in Katsina, MSF treated more than 107,000 patients with acute malnutrition, with 13,000 needing to be admitted for inpatient care.

MSF has six different outpatient feeding centres spread across Katsina. However, feeding is not enough. Children with malnutrition are more likely to become ill – and much more likely to die from their illness – than well-nourished children. Because of this, it’s crucial we provide medical services alongside the feeding program. The needs in our region are so high we have had to set up two inpatient centres.

This is how Musa came to us. When a fever and a persistent cough became worse, Musa’s mother Fatima* took him to her local MSF outpatient team. They compared his weight against what would be expected for a child his height, measured the circumference of his left upper arm and checked for fluid accumulation in his feet. The results were clear: Musa had severe, acute malnutrition.

The team arranged for Musa to be transferred to the MSF inpatient centre where I am based. We started him on F-75, a therapeutic milk especially formulated for severely malnourished children.

Next, we needed to treat his medical complications. Musa’s little body was struggling just to breathe. We suspected pneumonia – a common complication of malnutrition.

With the right care, children with pneumonia usually start to recover in three to five days.

But seven days after he was admitted, Musa was still severely unwell. His small body looked even smaller beneath his oxygen mask.

At this point, his mother Fatima got a call from home. Another of her children was seriously ill.

It is hard to imagine how she must have felt at that moment. She explained she and Musa would need to get back to their village as quickly as possible. She was hopeful the treatment he had already received would mean Musa would be well enough to make the journey.

Carefully, we explained to Fatima that was not the case. We had tried Musa on three different antibiotics and he was still very sick. He was still reliant on the oxygen therapy. We now suspected he had tuberculosis, which has very similar symptoms to severe pneumonia.

The head nurse, the health promotion team and I all came to support Fatima as she tried to make this impossible decision. She was juggling a lot of factors: how long it would take her to make the journey back, who she could rely on to nurse the sick child at home, who could take care of her other children if they fell sick too. I guessed at what she might be thinking: if Musa was too unwell to survive, it could be better to go now to try to give the other child a better chance. But if there was hope…

As a doctor you can’t make any promises in a case like this. Still, as I talked Fatima through the tuberculosis treatment we wanted to try, I felt like I was giving her my word.

At last we agreed: we would try the new drug and review the situation again in two days.

Two days. It was something.

We started Musa on the new medication. Twenty-four hours later he was breathing well enough to be taken off oxygen. However, he still had a bad fever. Progress, but not the remarkable recovery we needed.

On day two, when I asked Fatima about the situation at home, she hadn’t been able to get any news. She was anxious to go.

It felt like a gamble. Musa’s temperature was still high.

But Fatima’s bags were packed. So together, we made a plan. We would re-test Musa for malaria, so we could rule that out as a cause for the fever. We would give Fatima the medication, and she would follow the instructions as closely as a trained nurse. Lastly, she would come back to the hospital for follow-up as soon as possible.

It was all we could do.

I knew a follow-up visit might not be easy. Many of our patients travel long distances to reach our centre. Often they face tough financial decisions to afford transport. The challenges are so significant that many families don’t return at all.

The malaria test was negative. As Fatima left with Musa in her arms, I sincerely hoped our plan would work.

After one week, they were back.

Musa’s fever had gone. And Fatima was in a very cheerful state: her other child had also made a full recovery. We gave all the necessary medical advice and ensured the family would continue to get nutritional support through the local outpatient team.

Fatima’s determination during an incredibly difficult few weeks had left a deep impression on me. But she didn’t stop there.

A couple of weeks later, I got a message to say I had a visitor at the hospital. I recognized Fatima immediately. With her she had a well-nourished little boy holding a bookbag. It took me a moment to realize it was Musa!

They hadn’t come for a medical appointment. Instead, she’d come just to say thank you, and to show us how Musa was doing. The frail boy we’d seen a few weeks before was now well enough to go to school.

Sometimes people ask me how our team avoids losing hope. In the peak of the malnutrition season, when we are stretched beyond capacity, with more and more critically ill and malnourished children arriving every day, it’s stories like this that keep us going.

*Name changed to protect privacy.