buildings, plus accessory buildings containing exam rooms, procedure rooms, a nurses' station, an office, a storeroom, a pharmacy, our latrines and kitchen, and a small morgue. The buildings were rudimentary but solid—a concrete slab, block walls, corrugated steel roof covered with thatch, and wooden shutters. Deep, overhanging eaves provided shade where most of the patients spent the day; each had a straw mat, their bed, which they moved around to avoid the sun by day and moved inside the wards at dusk. Only the nurses' station, pharmacy, and clinic rooms had electricity, provided by a diesel generator. The generator had an evenmore important function—running the pump that filled our water tanks with the only potable water around; it came from a deep drilled well, or bore hole, as a well is called in Africa.

The inpatient roster included about 25 malnourished infants and children in the therapeutic feeding center (TFC). Most were under five years old and had fallen below 70% of the median weight-for- height ratio—due to a protein/calorie deficit, illness, or both. One of my first TFC admissions was quite a shock. Young Mohammed was nearly a year old but weighed only 5 lbs., 12 oz. It was hard for me to accept that he was not a newborn. Some of these kids wouldn't make it—they had come in too late for our medicines and formulas to have an effect. During my first two weeks in Galaha, four children died—two due to malnutrition and two to illness—more than I'd lost in 20 years of family practice in New Hampshire. The good news was that most of the TFC kids attained their target weight and were discharged. Of course, they returned to a tough environment.

About a dozen of the adult inpatients were very sick with TB. The other patients had a variety of acute and chronic illnesses, often compounded by chronic malnutrition, which significantly compromised their ability to heal. We averaged three or four admissions and discharges a day, and one or two deaths a week.

Emergencies came in the form of wounds, softtissue infections, broken

During my first two weeks in Galaha, four children died—two due to malnutrition and two to illness—more than I'd lost in 20 years of family practice in New Hampshire. But most of the TFC kids attained their target weight.

bones, meningitis, and either sporadic or epidemic "acute watery diarrhea"—usually accompanied by severe dehydration and often due to cholera. Our inability to test for and make specific diagnoses necessitated the use of euphemistic symptom-based diagnoses. Our resources, including the lab and pharmacy, were limited but adequate to provide good basic care.

By mid-morning I would head for the outpatient department (OPD), while Dr. Valeh visited the TB clinic, where she would see each of the TB patients every two to four weeks, depending on their phase of treatment. MSF's primary mission in Galaha was to provide TB treatment to the nomadic Afar. But the lack of primary-care services in the region

prompted people with a whole range of other conditions to travel for days to see us. The OPD, which I supervised, saw 50 to 100 patients a day. Two Ethiopian health officers, functioning much as physician assistants do in the U.S., would