The Medical Consequences of Starvation

Time​ Magazine

4 days ago

The 'worst-case scenario of famine' is unfolding in Gaza, the Integrated Food Security Phase Classification (IPC) warned in a July 29 alert, adding that 'access to food and other essential items and services has plummeted to unprecedented levels.' Widespread starvation, malnutrition, and disease are driving a rise in hunger-related deaths, the IPC, a United Nations-affiliated organization, added, calling for 'immediate action' to be taken to end 'catastrophic human suffering.'
'This is an incredibly important health catastrophe right now in Gaza, both in the short term and in the long term,' says Dr. Deborah Frank, a professor of pediatrics at Boston University's Chobanian & Avedisian School of Medicine, assistant professor of community health science at the School of Public Health, director of the Grow Clinic for Children at Boston Medical Center, and founder of Children's HealthWatch, which monitors the health of young children globally. 'It is fixable, but it's not a quick or easy fix. You need to have skilled people, and you need to have the supplies.'
According to the IPC, more than 20,000 children in Gaza were treated for acute malnutrition from April to mid-July, and more than 30,000 of them were severely malnourished. Gaza's health ministry said July 28 that nearly 150 people have died from malnutrition since the Israel-Gaza war began in October 2023, including at least 88 children.
A desperate environment
At the end of April, Dr. Aqsa Durrani, a physician and epidemiologist with a public health focus in humanitarian emergency response, returned to the U.S. after spending two months in Gaza with Médecins Sans Frontières, also known as Doctors Without Borders. She was there on March 2, when Israel reimposed a blockade on the Gaza Strip, preventing the entry of food, fuel, medicine, and other humanitarian aid. By the time she left, doctors, nurses, and patients at the trauma field hospital where she worked were eating one meal a day—a little bit of rice, she says, or maybe some lentils; certainly no substantial protein or significant amount of vegetables. 'We spent many of our days just trying to work with organizations to see where we could find more food sources and more nutrition sources for our patients,' she says. 'It was impossible. I had mothers and children sharing one portion of one meal every day.'
Read More: The Malnutrition Crisis in Gaza Will Outlive the War, Experts Warn
Starvation triggered "psychological torment,' Durrani recalls: 'I had mothers coming to me and taking me aside and saying, 'Do you have anything else you can give my child?'' The conditions have worsened since she left, and her colleagues tell her they're now having one meal every two or three days. 'They're performing surgeries while they're hungry and then going home to hungry children,' she says. 'It's quite harrowing.'
How starvation affects children
The impact of starvation varies from child to child and person to person, says Abyan Ahmed, global humanitarian nutrition advisor for CARE, an international humanitarian organization fighting global poverty and hunger. Factors like immune health and body fat play a role; if someone is already undernourished, their health will deteriorate quickly, after a few days without food. Children and adults who are a normal weight, or on the heavier side, meanwhile, might not experience the harshest effects of starvation for weeks or even months, especially if they're able to have intermittent meals.
When there's very limited access to food, the body flips into survival mode, first shutting down non-vital functions: the digestive system slows down, the reproductive system (ovaries and testes) may shrink, and growth and development stall. Once the body has used up all its stored carbs, it will start burning fat reserves and seek energy from the organs, muscles, and bones. Heart rate slows; blood pressure drops; body temperature declines.'The body is eating itself up to try to stay alive,' Frank says. Broken bones are common for children in this state. Malnutrition also weakens kids' immune systems, increasing the risk of infections like pneumonia, diarrhea, measles, and sepsis. While people can and do die from starvation, deaths are often caused by an infection, she adds.
In the short term, malnourished kids suffer mentally and behaviorally as well as physically. 'They're irritable, they're lethargic, and they're apathetic,' Frank says. 'They look miserable, and that's exactly how they're feeling. In fact, when you're slowly feeding a malnourished child, what we talk about is the smile sign: when they get to the point where they can smile, you're on the way up.'
Frank has worked with malnourished children who she initially worried were deaf or blind. 'They were so unresponsive when they were starving,' she recalls. 'Then you feed them, and indeed, this kid can hear and see. As they feel better, they start to interact and act much more normal,' but that recovery can take weeks or months.
Health effects in adults
Malnutrition affects adults in many of the same ways as it does children. 'When we think about how the body works, the initial stages of starvation will be the same for both men and women,' says Don Thushara Galbadage, an associate professor with the Harris College of Nursing and Health Sciences at Texas Christian University. In the first few weeks, 'they will experience fatigue, they will have muscle loss and muscle wasting, and they will have impaired cognition. And if it goes longer, some of their organ systems can malfunction and shut down.' 'We have seen, from case studies of starvation, that it takes up to 60 days before the body fully shuts down if the person has access to water,' Ahmed says. 'If you don't have access to water, you can die as quickly as three to five days.'
People experiencing starvation are often unable to concentrate and don't have the energy to complete basic tasks, like getting out of bed or taking care of their children. 'If a mother is malnourished, all those tasks become incredibly hard to do,' Ahmed says. 'That leads to depression and mental-health issues, which also affect malnutrition—because if you have mental problems, you're unable to look after yourself and eat properly, even if food is available.' Plus, she says, many women are overwhelmed and distressed by the sound of their children crying out of hunger.
Women who are pregnant or breastfeeding are especially vulnerable to the effects of starvation. Research suggests that expectant mothers in these situations are often unable to gain weight, and the risk of miscarriage and stillbirth increases. In one study, birth weight declined 9% during a famine, placental weight declined 15%, and length at birth declined 2.5%.
'In the third trimester, a lot of growth happens for the fetus, and when a mother is being starved, it has lifelong implications for the child,' says Ruth Gibson, a postdoctoral fellow in the department of health policy at Stanford University who specializes in global health, with a focus on improving maternal and child health in geopolitically complex regions. 'That includes things such as epigenetic modifications—so that's essentially when gene expression is changed—cardiovascular risks, chronic disease, and metabolic syndrome.'
How starvation interferes with wound healing
At the trauma field hospital in Gaza where Durrani worked, she mostly treated patients who had been injured by air strikes. Some had been burned by the resulting fires that rip through the region—and for their wounds to heal, they needed proper nutrition. If a child needs an amputation, for example, their surgical incisions may not heal because their body doesn't have enough protein to rebuild the tissue. In general, when wounds don't heal properly, the risk of infection increases. 'Very early on, I did have a baby die who developed an infection due to his nutritional status," Durrani says. 'If you think about a community that's being impacted by relentless air strikes—it's really just a layer of cruelty to add starvation to it.'
A lifetime of consequences
The effects of starvation can persist long after people regain access to food. 'What we can't see is the generational and intergenerational impacts' of the ongoing famine, Gibson says.
Research suggests that kids who experience malnutrition are more likely to have poorer health—including an increased risk of diabetes, heart disease, and obesity, as well as muscular-skeletal deficiencies—and developmental delays that persist throughout their lives. They're also at heightened risk of anxiety, depression, post-traumatic stress disorder, and mental illnesses like schizophrenia.
'Not only does it reduce their cognitive development, but malnutrition has been associated with poor educational attainment, with poor IQ scores, with a lack of income in later life, and not being able to keep jobs because of behavioral problems,' Ahmed says. 'It sets the person off to this cycle of poverty, which then gives birth to more malnutrition in their families.'
Addressing the chronic problems associated with malnutrition requires a systematic approach that likely isn't possible in Gaza in the near future, Ahmed says. For now, it's crucial to make sure as many people as possible have access to therapeutic nutrition support to help quell the immediate effects of starvation.'The priority right now is to keep as many people alive and get them to flourish again and get them back to a normal immune system,' Frank says, which can take a couple months in optimal conditions. 'But there's going to need to be long-term work for the children who survive, to decrease the chances of school failure, psychiatric disorder, and cardiovascular illness as they become adolescents and young adults.'
A looming threat: refeeding syndrome
When a child or adult has adapted to consuming very little food, they can't suddenly start eating a normal amount, even if supplies become available. Doing so could lead to a condition called refeeding syndrome, which causes a shift in fluids and electrolytes that can trigger cardiac arrhythmia, organ dysfunction, and death. 'On a less catastrophic level, you can get horrendous diarrhea and vomiting, which sets hydration back,' Frank says. 'It isn't just a matter of handing someone a box of cereal and saying, 'Go to it.' You have to be careful.'
It can take doctors who are working with malnourished children up to 10 days to establish safe, consistent weight gain, Frank says. Typically, doctors provide kids with only a small portion of the calories they actually need based on their weight, while monitoring their physiology and stomach tolerance for a couple days. 'You gradually build up over time, first to the normal caloric needs, and then to the needs for catch-up growth,' she says. 'People who are caring for these kids need to know exactly what they're doing. The idea that you can parachute boxes of food on the babies' heads and then expect them to grow—it doesn't work like that.'