Therapy Offers Swift Antidote to Starvation

The picture is hauntingly familiar: a Somali child lying on a burlap bag, emaciated. But with American troops clearing the way for food delivery, medical experts say that child may be walking, talking and taking normal food by Christmas, so swift and effective is the therapy for starvation.

Simple and cheap mixtures of sugar, salt and water--followed by a porridge of maize, beans, oil and sugar, boiled in a drum and stirred with a 2-by-4--jump-starts the process by which starving people become revived; if they are children, they quickly begin to grow again, say doctors recently returned from Somalia.

It is a public-health recipe well-tested in famines around the world over the past decade, the experts say.

“They start responding very quickly, within a couple of hours sometimes. Within a day or two, you’ll see someone who has been very unresponsive start to pick up,” says Dr. Alfred Sommer, dean of the Johns Hopkins School of Public Health. “Children who had been sitting in a corner a couple of weeks ago, and very sluggish, will literally be dancing around. It’s very dramatic.”

Malnourishment sets off a complex downward spiral in the human body, and the recovery of all severely debilitated adults and children in Somalia is by no means assured. But medical experts are optimistic that newly energized relief efforts will help most victims back to normal weight and functioning.

For months, missionaries in Somalia have been struggling to provide basic relief aimed at the majority of the starving--those who are not likely to die in the next day or week but might well die within a month, Sommer says. But most of the food has been looted by renegade gunmen and has not reached the starving. Now, with increasing rations expected to get through on a reliable schedule, an individual who is still strong enough to lift a spoon has a decent chance of recovery, doctors say.

Children receive a combination of ground grain, sugar and vegetable oil called Unamix. The powder comes in cement-like bags and is put in a drum and mixed with water or goat’s milk. The porridge is stirred and cooked for several hours while the feeding lines expand.

A few days of Unamix will significantly strengthen a child. But to restart their growth, related problems of dehydration, malnourishment, diarrhea and disease must all be battled.

Experts say it is sometimes hard for children to get past the first few bites after many weeks of starvation. Often, the body, so long without food, rejects the nutrition, says Sommer.

Diarrhea is the most immediate threat to health when the re-feeding process begins, says Dr. Dan Miller, an epidemiologist at the Centers for Disease Control and Prevention. It is often caused by disease, which is rampant; almost all Somali children have intestinal parasites. “With a child who is malnourished, if you don’t treat their underlying infections, parasites or respiratory infections, they won’t gain weight,” Miller says.

But many children also suffer from “re-feeding diarrhea.”

“During the process of starvation, the body tries to shut down nonessential functions in order to preserve major functions--the heart, kidneys, and brain,” Miller says. “So one of the things that is not replenished is the lining of the gut.”

The intestinal lining is a convoluted surface that continually sloughs off cells and makes new ones. But when the body is starving, new cells are not made and the lining becomes ineffective. “When you dump food into this lining it goes right through without being absorbed,” Miller says.

To treat this condition, children may be given oral rehydration therapy, small packets of dried salts that are added to water. But in Somalia, the water is usually not chlorinated and is contaminated with bacteria.

“That’s the problem. . . . The water is so contaminated,” Miller says. “The Somalis are instructed to boil the water and add the salts then. We also try to encourage them to set up oral rehydration centers for children with severe diarrhea so they can be rehydrated in a supervised setting.”

Children in this condition cannot tolerate more than a few spoonfuls of Unamix at a time, says D. J. Deming of the Agency for International Development in Washington. Deming spent a month in Somalia earlier this fall.

“They might get a bunch of small feedings a day instead of one or two larger ones,” he says. “You can’t just hand them an apple or they’ll die.”

A child who is dehydrated also has little saliva, is too weak to swallow and has probably lost the one thing that could motivate him or her to try: an appetite. If the Unamix is too thick, the child can’t swallow.

“It’s strong stuff. It will sit in kids’ throats and choke them,” Deming says.

But, given rehydration therapy and Unamix, the re-feeding diarrhea usually diminishes in three to seven days, Miller says.

Recent research also has revealed the importance of getting micronutrients--Vitamin A, calcium, iodine, iron and zinc are a few--to starving people as quickly as possible during re-feeding to prevent diseases and long-term health problems, such as blindness and growth retardation.

Given food, fluids and micronutrients, the rate of recovery depends not only on how malnourished the individual is, but on how many calories can be consumed and how fast. At least until now, there hasn’t been enough food to accelerate the pace of recovery. Severely malnourished children need feedings every few hours, something that has been impossible in relief centers up until now.

“Feeding the kids should take place every three hours around the clock,” Miller says. “Hopefully, with the troops there now, they might be about to secure areas where children can get the around-the-clock feedings they need to survive. The rations now are insufficient to promote much weight gain.”

But, if a child is not too seriously ill from other diseases and can be fed regularly, life will creep back into their eyes after a few days.

Deming says he was shocked when he saw how well a young boy, who two weeks earlier had been unable to lift a cup to his mouth, was revived with regular feedings of simple Unamix.

“He was happy and up two weeks later,” he recalls. “Children really rebound fast.”

Adults recover faster than children, Miller says, because they find other sources of food, no matter how meager. They also are less prone to diarrhea and have stronger immune systems to ward off diseases that interfere with re-feeding.

In children younger than 2, the privations can mean that brain development stops. “The most severely malnourished among the very youngest children may not reach their full intellectual ability. But they will still be smart enough to get along,” Sommer says.

Infants born to starving mothers are so underweight they rarely survive. Most malnourished women cannot produce breast milk.

A recent survey of relief organizations taken earlier this year found that the average child who arrives at a feeding station severely malnourished--weighing 30% less than normal--requires 3 1/2 months to improve to the point of mild malnourishment, which is 20% less than normal weight, Miller says.

But this survey reflects a period when food destined for feeding centers was regularly stolen and rations were scare. Now the timetable for recovery is expected to improve, although no can say how much.

And with regular feedings and some medical care to treat underlying disease, most Somalis will suffer no long-term health consequences from starvation, Sommer says.

“(Children’s) growth will pick up very quickly,” he says. “They may, in fact, catch up all the growth they lost.”