Johannesburg — FAHIZATOU Abdulaziz tries to scream. Her cracked lips part but only a low, keening moan escapes. Lying on a blood-red hospital bed in Tillaberi, a town about 140km from Niger's capital of Niamey, the two-year-old's wasted body contorts as she writhes in pain. She is dying. Her mother, Balkissa Hassane, holds her hand.

The child has the wizened face of an old woman. Her cheeks are sunken, her legs and arms reduced to little more than skin and bone. A paste of traditional herbs has been applied to her skull to prevent the fontanel from sinking in. She has a raging fever and is being treated for malaria.

"The child's chances of survival are less than 10%," Iqbal Karbanee - a paediatrician who accompanied the South African aid organisation Gift of the Givers to Niger last week - said after examining her.

"Fahiza was just lying there, barely able to move. She didn't even have the energy to cry. There is no body fat and no muscle mass. The heart, liver and kidneys have shrunk and become atrophied and the immune system is totally depressed. She is at high risk of potentially fatal diseases like gastro, pneumonia and measles."

Eventually her organs will begin to fail.

A year ago she would have been a "totally different child, running around and playing normally, possibly not well-nourished, but fairly healthy," Karbanee said.

In less than four months she has become a "walking skeleton". According to her mother, Fahizatou "became like that after I weaned her about three months ago".

"This is not due to any illness; it is due to a shortage of food. We come from an island in the [Niger] river, a little bit south of Tilla beri," she said. "I first took her to a small clinic but there were no medicines. They gave her herbal remedies that are made at home. The nurses for the clinic went around the district weighing children and said I must bring her to the hospital here. There is not enough food in the village."

In the markets of the capital, food is readily available, but 100kg of millet now costs $36 - a small fortune in a country where 64% of the population lives on less than $1 a day.

There is a persistent buzz of flies. Fahizatou's mother tries to brush them away with a yellow headscarf, but her efforts are in vain. They crawl over the child's face, into her nostrils, eyes, mouth and ears.

The wards are filthy and cobwebbed.

"It doesn't take a lot of money to keep the place clean," Karbanee said. "It is unacceptable that it is not swept out or washed daily."

In a corridor outside, a group of mothers and emaciated children take shelter from the burning 40°C midday heat and draining humidity. The muted cries of the children rise to an unbearable pitch.

Sweat drenches the clothes of the aid workers, pouring off their foreheads and into their eyes. As news of their arrival spreads over the next day, the crush becomes intolerable as hundreds descend on the hospital. Many are simply seeking reassurance that their children won't die.

"Everybody was just fighting to see a doctor," Karbanee said. "Many of the children were reasonably well-looking and the mothers just wanted us to listen to the child's chest or put a hand on the child and say they are fine. We gave them multivitamins and deworming treatment and they were on their way. They just wanted the reassurance that their baby was fine."

But dozens are dying. Many more mothers are not going to hospitals because they cannot afford the consultation fee of 250 CFA francs (about R3). Few seem aware that the government-imposed fee does not apply in cases of malnutrition.

In some villages in the Tillaberi region, residents said up to six children were dying each week. United Nations agencies estimate that 32 000 children are severely malnourished and could die. Between 2.5 million and 3.5 million people are facing grave food shortages.

Hadija Kandagoanni, a nurse at the town's hospital, said a "continuous" procession of sick, emaciated children had been brought to the hospital in the past year.

"Babies are dying. The mothers take them home to bury or they are buried at the hospital. I have seen a lot of cases like Fahizatou, but not as many as in the last week," she said.

It is a cliché, but Niger is a land the world forgot. The story is not new. The images that now haunt the front pages of newspapers and flicker across television screens are all too familiar from other countries and crises. And perhaps it is that familiarity that has sapped their power.

Niger last made international headlines in 2002 when a now largely discredited intelligence report suggested Iraq's Saddam Hussein had attempted to buy uranium from the country.

Mention Niger and the stock response is: "Where the hell is that?"

"South of Libya and Algeria, north of Nigeria, east of Mali - in the base of the bulge of Africa," you explain as the listener's eyes glaze over.

It is the second-poorest country in the world. Except for a tropical belt in the far south, along the banks of the Niger River, the country is arid and subject to the shifting, unforgiving sands of the Sahara. Average life expectancy is 42. For every 1 000 births, 120 children die. Most women give birth to six children. Many don't survive past the age of five. Deaths of women in childbirth are common.

The warning signs were there last year when hardly any rain fell during the height of what should have been the August rainy season. By October, the few crops that survived the drought had been devoured by locusts that ravaged 18 130km' of farmland.

The early-warning systems meant to detect an impending food crisis were in place and succeeded in doing so. It was the response that was a failure.

In November the UN appealed to donor nations for aid. There was little reaction. December's devastating tsunami took the world's attention elsewhere. While rock bands wowed crowds and attempted to draw attention to global poverty at the Live 8 concerts, children were dying in Niger.

Now, as aid is distributed in some of the worst-hit parts of Niger, other areas are being ignored. Aid agencies, politicians and commentators try to apportion blame, bicker about the numbers of those affected and debate the semantics of whether the disaster is a "famine" or a "severe food crisis".

"Everyone asks me whether it is a famine or not," said Stephanie Savariaud, a spokesman for the World Food Programme in Niger. "There is a big debate. I think it is a bit sterile because it shifts attention away from the real issue. We know children are dying and that is it. I think we should concentrate on the problem."

The response from Niger's government has alternated between denial and acceptance. Welcoming a donation of 36 tons of aid from South Africa, Lamratou Abubakar - a special adviser to Niger's President Mamadou Tandja and co-ordinator of the Food Crisis Secretariat - told reporters: "There have not been any deaths so far because of this food crisis... There have been deaths earlier because of malnutrition but not because of this particular hunger crisis."

Tandja himself drew the ire of the international community when he remarked in a BBC interview last week that "we have no people starving to death". He accused UN agencies of using "false propaganda" in order to get funding. He later said he merely meant there was no "famine".

Not long afterwards, he swept through Tillaberi, cocooned in a motorcade replete with a phalanx of heavily armed soldiers and an anti-aircraft gun.

At a stadium in Tillaberi, a crowd of more than 5 000 thronged outside the gates in the scorching sun as Gift of the Givers prepared to hand out food. Carrion birds circled overhead. As police opened the gates to allow small groups through, the crush intensified and people desperate with hunger fought to get through the crack.

In wave upon wave they collapsed as three policemen armed with sticks tried to beat them back. They struck them so hard the sticks splintered. Children caught in the seething crowd were lifted to safety.

When the day ended, about 2 000 people had received food parcels that are expected to benefit up to 10 000 people.

"Sadly, there is a lot of fatalism," Savariaud said. Starvation is a ghastly normality in Niger.

Already the tragedy is slipping from the pages of the world's newspapers. Soon the images of dying children will be forgotten, to be replaced by new disasters where the response has come too late.