It Takes More Than Food to Cure STARVATION

By MICHAEL D. LEMONICK

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.

As starvation advances, the body tries to conserve energy by limiting all but the most vital processes. Cell division slows drastically. Even hair stops growing. Reduced fuel burning drives body temperature down; that, combined with the loss of insulating fat, can lead to death from hypothermia -- a threat on a cool Somalian evening. The shutting down of the intestines can lead to the paradox of death by diarrhea. Reduced production of white blood cells weakens the immune system, a kind of starvation-induced AIDS that turns diseases like measles into killers. Eventually the body begins burning muscle tissue wholesale: victims become too weak even to move, and the heart muscle begins to shrink. By then death is almost inevitable.

Because starving bodies are so severely disrupted, it takes more than good meals to restore them. In fact, too much food too suddenly can kill victims by triggering shock. The process of refeeding, which in Somalia will take place mainly in huge feeding camps, usually starts with fluids to counter dehydration. Then comes a high-calorie, high-protein mixture such as the U.S. government's Unimix, made of ground beans, ground rice or corn, sugar and vegetable oil. This is given in frequent, small meals so that the out-of- practice digestive tract can handle it. Severely malnourished children may require hourly feedings. "They are hard to rehabilitate because they are lethargic and lose their appetite. They turn their head when spoon-fed," says Dr. Graeme Clugston, chief of the World Health Organization's nutrition program.

Within weeks after refeeding begins, even those adults who were on the verge of death will have largely recovered. But children, especially those under five, can carry the scars for life. They can go blind from lack of vitamin A. They may never achieve their full height. Girls may never be able to safely bear children because of malformed pelvises. And mental function is often impaired. "Even when they are fed and back on their feet, you'll have a generation of kids with a considerable degree of retardation," says Michael D'Adamo of Catholic Relief Services.

The feeding camps will operate until the Somalis regain enough strength to start producing their own food again. Herds of cows, goats and camels and stores of seeds, all long since eaten, will have to be replaced. After that, Somalia has a chance to be self-sufficient once again -- as long as social and political stability are restored.

With reporting by Farah Nayeri/Paris and Dick Thompson/Washington