It Takes More Than Food to Cure Starvation

AN ALARMING SIGHT greeted American health officials visiting the town of Hoddur in Somalia. Relief workers had distributed unmilled wheat to starving villagers, and scores of living skeletons were pounding the wheat by hand in order to make an edible mush. To the casual witness, the rhythmic thuds might have seemed the music of deliverance, but to those familiar with the grim calculus of starvation, they formed a dirge. The energy expended in grinding the wheat vastly exceeded the nutritional benefit of the mush. Relief supplies were killing the starving.

The tale underscores the difficulties of helping people who are dangerously malnourished. Starvation is a complex biological process; the more advanced it is, the dicier the treatment. During the famine in Somalia, perhaps the worst ever recorded, average food intake for adults has dwindled from a satisfactory 1,700 calories a day in 1988 to a hopelessly inadequate 200. A majority of children under the age of five have already died in some regions. "The mortality is higher than that of the Irish potato famine," says Daniel Miller of the U.S. Centers for Disease Control and Prevention. "It's the worst nightmare you could think of."

Children are affected more severely than adults by famine. The reasons are tied to the biochemistry of starvation, which has been documented both in the fields of human tragedy and in labs with fasting volunteers. In essence, the starving body consumes itself, devouring its own fat and muscle while shutting off less important systems to keep the brain and the rest of the central nervous system operating. Children simply have less fat and muscle to consume.

The first, mild stage of starvation begins within hours after food intake stops. The body quickly burns through its reserves of sugars in the blood and starches stored in the liver and muscles. It then begins raiding fat deposits for triglycerides, compounds that can be broken down into fatty acids that the body can use for fuel. After days or weeks, depending on how meager the rations, these raids result in a condition known as marasmus. Without fat to support it, the skin begins to lose elasticity and sag. Loss of fat around the eyes gives them a sunken look, and the face starts to wrinkle in what starvation experts call the old-man syndrome. The other principal form of starvation, kwashiorkor, is largely a protein-vitamin-mineral deficiency. Its most common symptom: swollen legs and ankles, caused by fluid leaking from blood vessels into the body.

If people could survive on stored fat alone, those who are well padded could survive quite some time. But human metabolism is not so simple. The brain, consumer of about 20% of the body's energy, cannot burn fatty acids. It needs glucose, a form of sugar. And the major source of glucose in a starving body is protein. The first proteins to go are digestive enzymes in the stomach, pancreas and small intestine and nutrient-processing enzymes in the liver, no longer of much use anyway. Then the muscles begin to wither away, giving limbs a sticklike appearance.