Stephen Flanagan is a nurse working with Médecins Sans Frontières (MSF) in southern Sudan, an area where MSF is seeing worrying levels of malnutrition in children. As part of his job, Stephen assesses children and helps them get life-saving treatment for this threatening but treatable condition. In June he participated in one such assessment. “It’s red,” my colleague calls out to me, so I make another tally mark on our data sheet where ‘red’ results are increasingly becoming the norm. We walk to the next house and find another red, and then another some moments later. After assessing over 300 children, we decide to take a break away from the southern Sudanese heat – it is 46 C and only 11a.m. For those children who have a mid-upper arm circumference (MUAC) scoring of red, meaning that they are severely malnourished, there is a significantly increased risk of dying. MUAC measurements are a quick and simple process whereby a measuring band is placed around the upper arm. A reading is then made and the measurement indicates the severity of their nutritional status. We continue throughout the day, walking from house to house, assessing every child in the village. We come across one small girl who clearly needs admission into our in-patient feeding program. The girl, four years old, is quietly listless in the arms of her mother, whose face is a mask of hopelessness. I take the measurement of the child’s arm. It reads a circumference of 9.8 centimetres – clearly another red, and clearly at risk of dying. You can see for yourself just how malnourished this child is. Get a piece of string now and measure 9.8 centimetres. Make it into a circle and there you have it – the upper arm circumference of this four-year-old girl. You do not have to be an expert to know that this arm is far too thin. Understandably, the mother initially refuses permission for her child to be admitted to the hospital – she has three other children, so who will look after them? After some negotiation she agrees, and the child is taken to the hospital in Leer where MSF provides for special feeding. The next day we leave by landcruiser and head to a remote area that we know has experienced food shortages before. However, it is not long before swampy ground forces us to abandon our vehicle and continue on foot. It takes us most of the day before we arrive at our destination, set up camp and rest in preparation for more long days ahead. After two weeks, having assessed 12,000 children, we sit eagerly awaiting the analysis of our results, although we know in the back of our minds what it will be. Arriving back in Leer, we support the staff in the hospital in-patient feeding facility. More than 20 of the patients are critical and, if they were in a developed country, would be in an intensive care unit. One small child arrives, dehydrated and limp. We start initial emergency treatment but for this two-year-old, the complexities of his condition are just too much and he dies shortly after admission. I have worked in a feeding program before and always ask myself afterwards if it becomes any easier, seeing a child die of hunger. In reality, you are just too busy to think about it. There are positive things about working here; it is not all doom and gloom. There’s nothing better than seeing a bouncing, lively child discharged home after watching them improve from a condition where they were so weak they were unable to stand. And many, many children do go down this route. From January to April this year there was a 200 per cent increase in the number of children admitted into the program as compared to the same period last year, and it was here in Leer that alarm bells first began to ring. Children were, and still are, arriving at an increasing rate each day. I checked the attendance figures this morning [June 17] and there are more than 500 children admitted to the program; six weeks ago, when I first arrived, it was 205. Apparently the other feeding programs run by MSF in Lankien and Nasir are both seeing similar increases. Malnutrition is complex. Although now is the start of the traditional hunger gap in southern Sudan, the situation has been compounded by an even worse than usual harvest, plus sporadic insecurity following recent elections. Food prices in the markets have increased by more than 100 per cent since January, and people here are helplessly doing what they can to manage. We have increased our capacity drastically in Leer to care for these children. But, following our assessment, there is a clear need for intervention now, and this will increase in the coming weeks and months. Without the specialist feeding care we can provide, the situation will only become much worse. And that’s the next challenge. Plans are already underway to access more areas. That is what I like most about MSF: the freedom to be able to see the problem, then get stuck right in and get on with the job.