For want of a donkey, three-year-old Deqa lies unconscious in an intensive-care unit, severely dehydrated and so malnourished that his skin hangs loosely on his thin body.
For months, his family has been stranded in a makeshift shelter in the scrub bush outside Mogadishu. They could not reach their destination, the refugee camps of the city, because their donkey died during the arduous 10-day journey from a famine zone controlled by Islamist militants who reject all foreign aid.
Only when Deqa's father managed to scrape together some money from odd jobs was he able to take the child to the hospital by minibus. By then, it was nearly too late.
Banadir Hospital, one of Somalia's biggest, is overwhelmed by hundreds of cases like Deqa's as the famine deepens. The wards are jammed full, with mattresses covering almost all the floor space in some rooms. With a shortage of doctors, many patients are seen by junior medical students, and there aren't enough staff to monitor the patients properly.
Yet those who reach the hospital are the fortunate few. Most famine victims are in regions controlled by al-Shabab, the Islamist insurgents. And because of poverty and illiteracy, even the children in government-controlled regions can die without the treatment they desperately need.
Distances that could easily be overcome by a car are nearly insurmountable for impoverished parents with large families of sick children. Sometimes a mother removes a still-weak child from hospital because she needs to go home to care for her other children.
The United Nations announced on the weekend that 13.3 million people need urgent assistance in the drought and famine zones of Somalia, Kenya, Ethiopia and Djibouti. The total has increased by nearly one million people as the UN improves its assessments across the region. Hundreds are dying daily in Somalia, and a further 750,000 are at risk of dying.
In a country where 20 years of civil war has fostered one of the world's highest illiteracy rates, many Somalis have no trust in hospitals or Western medicine. For example, in cases of measles, directly linked to the famine because of the low immunity of the malnourished children, the parents often prefer to treat their ill children with traditional rural remedies, covering their bodies with cooked tree leaves or the blood of a goat. Meanwhile, the child can be deteriorating into permanent disability.
"Sometimes they only come in to the hospital when their child is already blind," said Lul Mohamed, head of pediatrics at Banadir Hospital. "It's due to ignorance and a lack of education."
In one hospital room, three malnourished children from the same family are severely ill, probably from measles. When one child dies, their father blames the hospital. He pulls out the surviving children and takes them back to his refugee camp. "There's no good medicine here," he says angrily. "I have to take the children home."
Within a few hours, the children are back at the refugee camp, without aid. And the next day, another of the children dies.
Alan Lefebvre, emergency co-ordinator at the Mogadishu operation of Médecins Sans Frontières, says a severely malnourished child should receive up to 10 days of treatment with specially enriched food. But the mother sometimes takes the child home after just two days, as soon as the child is feeling a little better, because she needs to care for her other children. "We can't force anyone to stay," he said.
In other cases, he said, a mother can trek from hospital to hospital, desperately searching for treatment for a dying child who cannot be saved. In those cases, MSF can only advise the mother to stay in one place, and the agency tries to give comfort in the child's final hours. The agency keeps a supply of burial shrouds on hand.
Geoffrey York