In Niger more than two million children are entering the peak of what authorities say is a particularly devastating hunger season causing a severe risk of malnutrition-related fatalities.
Niger has a long history with hunger as chronic food shortages stretch from May to September. The hardest days of the hunger season are approaching. Dr. Susan Shepherd is a medical advisor for the aid group Doctors Without Borders.
"Families are basically subsisting on small amounts of millet porridge, and this of course is the equivalent of trying to ask a young child to grow and thrive on bread and water," says Dr. Shepherd. "So it's not surprising that children, they lose weight, they become increasingly vulnerable to common infections and malaria also starts to exact its toll."
The group is delivering vitamin-fortified milk powder to between 150,000 and 300,000 children in a year that authorities say is worse than normal.
"But every year is a particularly bad year in Niger," she adds. "It's just a matter of degrees."
In the capital Niamey, and in regional health centers, Shepherd says national authorities have shown progress in charting the local response to the annual emergency. She says each year the country's health ministry has increasingly fine tuned its now five-year-old national anti-malnutrition program.
Niger's doctors and nurses, she says, have more tools and more training to combat malnutrition, and international aid groups are doing more preventative work, distributing high value supplementary food to children before the hunger season starts.
"I think there is an increasing recognition of that need," says Shepherd. "But every year I've worked in Niger we've taken care of increasing numbers of children regardless of whether harvests are good or less good. It's difficult to say that for the children in Niger things are overall getting better."
Like its Sahelian neighbors, Niger is a wide and rural country whose far-flung population is often difficult to reach for food aid and medical teams.
Shephard says that's why aid groups must do more in the offseason to fight malnutrition and prepare staff and supplies for the yearly hunger months.
"We know this is coming and there's no need to scramble for last minute program," she added. "We're arriving too late. Protective and preventive programs start best when they start early."
The United Nations World Food Program estimates life expectancy in the country at just over 44 years. And that does not include the one-out-of-every five children in Niger who do not survive past the age of four.