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Just as I was about to leave for the day, Steve, one of the nurses, asked me if I could see this one case before going. Beatrice (not her real name) was two years and seven months old when she arrived in our paediatric hospital tent, in Kimbi Lulenge, South Kivu, in the Democratic Republic of the Congo (DRC). A quick glance at the prostrate child in the dim circle of light cast by the tent's single bulb and I guessed she was another malaria case. Steve shook his head. "Non, docteur. C'est un nouveau cas de malnutrition" ("No, doctor. This is a new malnutrition case").


I quickly felt the child's feet – icy cold. A careful look at Beatrice showed that all the curves and dimples of a healthy child's face had shrunk, leaving the forbidding lines of a woodblock print. Beatrice was alert, but silent, which formed an ominous void amid the children crying in the rest of the tent. There was a glint of anxiety in her rheumy eyes that grew dimmer as she seemed to fall into it.


I gently pulled back the cotton wrap. The malnutrition had ravaged her skin, causing it to flake off, leaving behind weeping sores across her arms, legs and chest. There was no healthy protest when a drip was placed in her arm.


The nursing staff went into action. They gave her glucose to prevent low blood sugar, antibiotics through the drip to fight off infection; they advised her mother to keep her warm, as hypothermia takes the lives of many of these children at night. Careful fluid management and gentle refeeding was started: give too little and the child will succumb to dehydration and shock; too much and the child will die of heart failure.


Treating a malnourished child is complex. It is not simply a matter of doling out cups of milk and packets of peanut paste when a child like Beatrice finds her way into our tent, tied to her mother's back after she has walked a day to get to our hospital or, if she's lucky, on the back of a relative's motorbike along the treacherous dirt roads.


She needed intensive care; the kind of care where one nurse sits at the foot of her bed, monitoring her temperature and vital signs hourly, helps to prepare the mother for the full timetable that refeeding these children requires, and attends to the skin wounds that look as though they belong to a burns victim.


This situation of need in the midst of such want brings to mind the work of the British doctor Julian Tudor Hart. In the 1960s, he pioneered pro-poor healthcare in the Welsh town of Glyncorrwg. His experience prompted him to come up with the "inverse care law" - that the "availability of good medical care varies inversely with the need for it in the population".


The grand-sounding Inpatient Therapeutic Feeding Centre (ITFC) is my favourite part of the hospital. In a tent set apart from other patients you get to see these little children, with so much stacked against them, gradually put on weight, start to smile and play with their parents. With the extra staff we have hired, our care is as focused and intensive as it can be, given our limited means.


But Beatrice arrived before our ITFC had been established. That night there were only two frazzled nurses in our paediatric tent. It was rainy season so it meant malaria cases were high and our hospital was busy.


Beatrice arrived when the light was fading behind the tent's white canvas walls; she was already very ill. After gently warming her by placing her close to her mother and monitoring the dosing of the initial fluids, Steve began her feeds. He tended to her skin and then, when she began to have difficulty breathing, he put her on the hospital's only oxygen concentrator, the maximum level of care for our most severely ill children.


But when I was called to see her later the next morning, her heart had already stopped. The anxiety in her eyes had gone.


Beatrice's mother sobbed as we wrapped her daughter in the green cotton cloth in which she was brought. Her father lifted her easily in his arms and left the hospital, his face immobile. Her mother walked, crying, behind him, stopping on the dirt road from time to time as she doubled up in grief. An elderly man going the other way, a Red Cross armband on his left arm, dismounted his bicycle and gave a formal salute to the family as they walked past.


You won't read much about malnutrition in DRC because it doesn't fit the dustbowl paradigms that govern the concept of starvation or malnourishment. Where I am in the east it is green and lush, but after years of war, insecurity and economic collapse, all the children in our tent are malnourished to some degree. It is this underlying weakness that determines how children respond to the infectious diseases that claim their lives with unrelenting regularity.


An estimated 9.7 million children under the age of five will die this year of largely preventable illnesses. Malnutrition is estimated to contribute to half of these deaths. What do numbers like these really mean?


It means a small, fragile girl like Beatrice, whose parents loved her, who left us as quietly as she arrived.

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Our team arrived to start working at the Lulimba hospital at the height of the malaria season. We barely had time to unpack our boxes because we were greeted by a crowd of sick children, and more have been arriving in ever-greater numbers since. We also found out very quickly that the hospital had only one thermometer.

When you are unable to do most tests, being able to take someone's temperature in an area endemic for malaria and other tropical diseases is critical. So the staff spent the first few days running between the outpatient clinic, maternity, paediatrics and internal medicine, chasing the small tube of glass and mercury needed to place under the arm of a hot, lethargic child. We found two more thermometers in MSF's own medical kits, kept in our vehicles.

The lack of thermometers is only one of many shortages that beset the hospital, which is now trying to cope with a surge in patient numbers since healthcare was declared free with the arrival of our team.

There are plans to build a new hospital. But in the meantime, we are roaring through our first supply of medications, especially antimalarials and paracetamol. The number of children is growing, with two or three having to share a mattress, along with mothers and often siblings. The hospital staff are overworked, but are handling the white-water ride of this startup with patience and humour.

When I asked one mother, after seeing her child, if there was anything else I could do to help, her reply in Swahili prompted laughter from the other mothers. The nurse on duty, Silele, grinned and translated for me: "She was asking if you could sort out the problems between her and her husband, but I think we have enough to do already.''

The shortages, particularly of nursing staff, impede our work at every turn. At the start, we lacked a rapid test for malaria (there's apparently a shortage of these tests across the globe) and the large number of children presenting with fever overwhelmed the tiny lab; a dusty little room where the single microscope is placed carefully in front of a window to capture enough light to be able to search for the parasites that plague our patients. The lab technicians use a torch at night to bounce off the microscope's mirror.

In the operating theatre the patient is anaesthetised with ketamine, and a small wisp of cotton wool is placed over one nostril. If it moves up and down, the operating team knows the patient is breathing. The wisp of cotton wool in place of winking, bleeping machines found at the anaesthetic end of operating tables in the UK is the perfect illustration of why a certain phrase in French is never far from everybody's lips – Il faut se débrouiller! (You'll just have to muddle through).

Building a hospital takes time, but the flood of patients means we've had to improvise quickly. We've moved the internal medicine and paediatric services out of their overcrowded, dark rooms into four large tents while we wait for the new hospital. This has also created space for other services.

We now have bed nets for each patient to prevent the mosquito vector from spreading malaria from one patient to another. Each service has buckets with chlorinated water for drinking and hand-washing to help prevent cross infection.

The operating theatre now has a light, and the instruments are properly sterilised, instead of being placed in pressure cookers on charcoal braziers as they were when we arrived. We now have a generator that we can use to provide oxygen to patients with breathing problems. We simply treated all feverish children for malaria until the rapid tests arrived. When we started collecting data from the tests, 85% of them were positive for the potentially deadly P falciparum form of malaria.

I was woken this morning by a crack of thunder and the pummelling of heavy rain on the tin roof. The rains threaten more malaria and more patients, and the already parlous dirt roads and airstrip that we rely on for the delivery of drugs and equipment that this isolated hospital so desperately needs.

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Long journeys in the Democratic Republic of the Congo are a part of the dizzying extremes in this country dripping with precious minerals but where one in five children die before their fifth birthday. Of the 153,497km of mapped roads that cross the territory two-thirds the size of Europe, only 2,749km are paved. As soon as we leave the outskirts of Bukavu, the main city in South Kivu province, the Tarmac ends.

I'm heading for Lulimba, a small, remote town in eastern DRC. It's 300km from Bukavu but the journey takes two days in a four-wheel drive vehicle. You can't fly in as the dirt airstrip, originally cleared by a long abandoned church mission, is reported as uneven and potholed. The jolts along the red-dirt tracks, river crossings full of children splashing about (I wonder how many of them carry the worms of schistosomiasis) and short exchanges with armed men en route make it impossible to study the French grammar book open on my lap.

My own journey to DRC as a doctor has taken a little longer. Before medical school, I worked as a reporter on frontlines from Bosnia to Afghanistan. Refugees, civil wars, political unrest – these were the stories I wrote about from the field.

Reporters gravitate towards hospitals and clinics because they provide the starkest index of suffering among populations trapped by conflict. I spoke with doctors and nurses behind many frontlines and the more I talked with them, the more difficult it became to simply take notes while they risked their lives to treat the sick and wounded, often with minimal medications and equipment. I put down my notebook and entered a London medical school.

A decade on, driving past a bar painted a marine blue and called Clinique a la Soif (Thirst Clinic), I worry about the sudden increase in my clinical remit. As a doctor in the UK, I manage patients in a busy emergency department but I don't have to worry about getting hold of antibiotics or a chest X-ray. In the DRC, which sits at the bottom of the UN's Human Development Index, resources are scarce. I've been warned that as well as seeing patients, I'll need to keep track of hospital supplies, possibly face widespread cholera or measles outbreaks, and must help set up treatment for patients with tuberculosis and HIV, both diseases that come with complex pathologies and social issues that are challenging to treat anywhere, let alone in isolated Lulimba.

When we arrive, our truck carrying about a tonne of precious medications is lurched over at a 45-degree angle, stuck in the mud on the main street. There is no electricity for the squat homes made of mud brick and reed thatch. When the MSF team arrive at the town's hospital – two single-storey buildings of mud brick roofed with iron – we tell the staff about our plans for free healthcare. That evening, the staff enthusiastically remove the handwritten posters listing the prices for treatment.

Overnight, word gets around. The next day a large crowd of women wearing brightly printed cotton wraps clutching coughing, feverish children, assemble outside the dilapidated outpatient building for a free consultation. Georges, one of the hospital nursing staff, looked a little forlorn in his white coat. "Treatment is free, so now everyone will come!" he says.

Before MSF's arrival, the hospital saw 231 patients in the month of September. We've seen more than 300 in our first week.

The hospital is situated on a low rise in lush grassland at the foot of Kivu's spare Mitumba mountain range. The beauty of the place belies the population's desperate healthcare needs. On my first day, I found a 14-month-old toddler in the paediatric ward who weighed 5kg. He is suffering from marasmus, a severe form of malnutrition with the typical pinched "old man's" face. He has to share a tattered bed with another sick child as there aren't enough cots. Sharing is dangerous as the malnourished child's immune system is unable to fight infections. Nurse Pierre and I are currently treating the TB, which likely underlies his malnutrition while starting a careful therapeutic feeding regime. Pierre, who has much experience with these cases, is optimistic.

The hospital's doctors, Serge and Albert, ask me to attend a caesarian section in the operating theatre. This is a bare room with no electricity or lamp. They depend on a plastic skylight in the roof to see what they're doing during the day, and use head torches at night. They don't expect the baby to survive as the mother's uterus was ruptured. They were performing the operation to save the mother's life. But with a few puffs of air delivered by a bag and mask to inflate the baby's lungs, the little girl lets out a cry. Both mother and baby are doing well.

Underlying Lulimba's health problems is the DRC's conflict. In 2009, the hospital was attacked by an armed group that destroyed or stole many of the building's meagre resources. But if the needs are great around Lulimba, one can only imagine those in Congo's even remoter areas. To get to Lulimba, we had to drive through an area called Foret 17, notorious for banditry and the constant to-ing and fro-ing of the many armed groups that roam South Kivu. At an isolated health post nearby, the nurse in charge said recent fighting had driven hundreds of villagers into the forest. They will have no help to fight the malaria, pneumonia, diarrhoea and other treatable illnesses that continue to cause so many deaths in Congo.

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Promoting resilience is a growing area of interest in development. The UK Government’s Humanitarian Policy ‘Saving Lives, preventing suffering and building resilience’, puts resilience at the heart of their approach. Building on this, DFID have committed to embedding resilience-building in all of its country programmes by 2015 and integrating resilience into all of their work on climate change and conflict prevention.

Practical Action sees resilience as the ability of a system, community or society to resist, absorb, cope with and recover from shocks and stresses. A resilient community is one in which people can manage risk and recover from shocks such as floods, droughts and violent conflict. It also means people have the ability to adapt to long term trends such as climate change in a timely and efficient manner without undermining their wellbeing.

How to operationalise concepts of resilience is a challenge for many organisations. Practical Action has developed an approach called From Vulnerability to Resilience (V2R). This is a framework that analyses the causes of vulnerability and how disaster risk reduction, climate change impacts, governance and livelihoods interact and affect resilient outcomes.

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I had never met a slave before I went to Pakistan. It’s a strange feeling to talk with someone who is owned by another man. Yet, here he was: 61-year-old Ghulam Rasool telling me how four generations of his family had lived under the control of a rich landowner.

The inequality of Pakistani society strikes you almost the minute you get off the plane. This is a country where unimaginable wealth and unthinkable poverty live side by side; a country that boasts nuclear weapons and starving children.

Those inequalities were highlighted by the floods which devastated Pakistan this time last year. Twenty million people – the vast majority of them small farmers - were left homeless as the River Indus burst its banks and covered the country.

One year on, the evidence of the devastation can still be seen throughout the Sindh Province of southern Pakistan, which was one of the areas worst affected. Of the millions forced from their villages, most have managed to return home, but tens of thousands remain living in tents by the roadside.

Some, like Raju Solangi, the 12-year-old boy I met whose one wish is to be able to go back to school, are simply unable to afford the journey back to their home towns. Others, like Ghulam Rasool, refuse to return to their lives of slavery, insisting that their new life – a life without money, food, cooking facilities, sanitation or a roof over their heads – is better than what they knew before the floods came.

“I would rather die than go back,” said Ghulam as he told me of his life as a slave.

These are the forgotten people. The people who, twelve months after the floods, are living in limbo; unable to stay where they are but with nowhere else to go.

Even those who have returned home are finding that life post-flooding bears little resemblance to the life they once knew. Sher Mohd Khoso is from a fishing community on the edges of Manchar Lake. The people here never had much – they had no crops, no industry, no farms. They survived solely on the contents of Manchar Lake for their survival. There was a cruel irony in the lake rising up and destroying everything it had ever given them.

Like 20,000 others, Sher Mohd Khoso was rescued from the flood by Trócaire’s partner organisation, the Pakistani Fisherfolk Forum. For three months, Sher and his community survived on the generosity of the Irish people who, through Trócaire, provided them with tents, food, water, medicine and other essential items.

They were thankful for the help but understandably eager to return home. When the flood water finally receded, Sher and the people who lived on Manchar Lake made the journey back to their villages. Their homes were washed away, their few possessions gone. Worse still, many of their boats and fishing nets were destroyed beyond repair.

Sher has not been able to fish since before the floods. He has no means to provide for himself or his family, instead relying on the generosity of his friends. They are glad to help, but as pollution steadily decreases fish stocks in Manchar Lake finding food for everyone is becoming increasingly difficult.

This is now the reality of life for many of Pakistan’s 170 million people. The floods of 2010 have left a devastating scar on a country already ravaged by dehumanising poverty. Far from the image of religious extremism now so widely associated with the country, the vast majority of people in Pakistan are waging a far more fundamental battle: that for survival. It is food and education that concerns them, not geopolitics.

People in Pakistan want a future; they want something for their children to aspire to. The floods of 2010 have laid bare the poverty and inequality which acts as a daily reminder that at the moment they do not have those rights.

But still they dream. In an abandoned building close to the tent she now calls home, Gulshad Chandio remembers the friends and life she left behind the day her family escaped the floods. She misses a lot about her old life but this 8-year-old misses one place more than anything else: her school.

Gulshad wants to learn because she wants to be a doctor. Not just any sort of doctor, either – Gulshad wants to be a doctor who helps those who need it most.

"I want to go back to school so as I can become a doctor," she says. "When I become a doctor I will not charge people - I will give health for free."

At the age of just 8, Gulshad understands that healthcare is a privilege reserved for the rich. She understands that her society is divided between those who have too much and those who have nothing at all. And, as she settles into her thirteenth month squeezed into a tent on wasteland outside of Hyderabad City, she realises that her family have nothing at all.

Maybe Gulshad will become a doctor, but this is Pakistan, a country which boasts the highest childhood illiteracy rates in the world; a country which has been unable to put a roof over her head.

The odds are against her, but maybe, even in Pakistan, there can be such a thing as a happy ending.

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