Anne Barnard / The New York Times – 2013-11-05 01:00:07

http://mobile.nytimes.com/2013/11/03/world/middleeast/stick-figures-and-stunted-growth-as-warring-syria-goes-hungry.html

BEIRUT, Lebanon (November 2, 2013) — Rana Obaid began her life less than two years ago in a comfortable house draped with roses, the daughter of a grocer locally famous for his rich homemade yogurt. But war and siege brought hunger so quickly to their town near Damascus that when she died in September, at 19 months, her arms and legs were as thin as broomsticks.

In a nearby town, a woman with a son suffering from kidney failure makes her children take turns eating on alternate days. In a village outside Aleppo in northern Syria, people say they are living mainly on wild greens.

Aid workers say that Syrian refugee children are arriving in northern Lebanon thin and stunted, and that suspected malnutrition cases are surfacing from rebel-held areas in northern Syria to government-held suburbs south of Damascus.

Across Syria, a country that long prided itself on providing affordable food to its people, international and domestic efforts to ensure basic sustenance amid the chaos of war appear to be failing. Millions are going hungry to varying degrees, and there is growing evidence that acute malnutrition is contributing to relatively small but increasing numbers of deaths, especially among small children, the wounded and the sick, aid workers and nutrition experts say.

The experts warn that if the crisis continues into the winter, deaths from hunger and illness could begin to dwarf deaths from violence, which has already killed well over 100,000 people, and if the deprivation lasts longer, a generation of Syrians risks stunted development.

“I didn’t expect to see that in Syria,” said Dr. Annie Sparrow, an assistant professor and pediatrician at Mount Sinai Hospital in New York, who examined Syrian refugee children in Lebanon and was shocked to find many underweight for their height and age.

“It’s not accurate to say this is Somalia, but this is a critical situation,” she said. “We have a middle-income country that is transforming itself into something a lot more like Somalia.”

While the war has prevented a precise accounting of the number of people affected, evidence of hunger abounds. The government is using siege and starvation as a tactic of war in many areas, according to numerous aid workers and residents, who say that soldiers at checkpoints confiscate food supplies as small as grocery bags, treating the feeding of people in strategic rebel-held areas as a crime. Rebel groups, too, are blockading some government-held areas and harassing food convoys.

But even for those living in more accessible areas, what aid workers call “food insecurity” is part of Syrians’ new baseline. Inflation has made food unaffordable for many; fuel and flour shortages close some bakeries, while government airstrikes target others; agricultural production has been gutted.

Though the World Food Program says it is providing enough food for three million Syrians each month, its officials say they can track only what is delivered to central depots in various cities, not how widely or fairly it is distributed from there.

One aid worker — who, in a sign of the political challenges of delivering aid in Syria, asked that his organization not be identified — said he recently met Syrian health workers who reported a dozen cases of apparent malnutrition in a government-held Damascus suburb. He suspected that the situation could be far worse in rebel-held areas.

Lack of medical care and clean water exacerbates the problem. So does the fact that Syrians have little experience diagnosing or treating malnutrition. Particularly troubling, aid workers say, are reports of mothers who stop breast feeding, unaware that it is the best way for even a malnourished mother to keep her child alive.

Some aid groups are trying to train Syrian doctors to use simple tools that measure upper arm circumference to assess malnutrition, as convincing data on its prevalence could help spur a stronger international response. Aid workers caution against overblown claims that could discredit such efforts.

Some government supporters even dismissed the images of bone-thin children from blockaded areas as propaganda after several thousand civilians were evacuated from the encircled Damascus suburb of Moadhamiya in recent weeks, looking exhausted, shellshocked and thin, but not on the verge of starving to death.

But an entire population does not have to appear skeletal for malnutrition deaths to be real, the experts say. Malnutrition, they say, strikes the most vulnerable first: babies and children; those suffering from diarrheal diseases; those who need extra nutrition to recover from wounds or manage chronic illnesses; and those who lack the money or connections to obtain the food they need.

In traumatic situations, cases may go unnoticed until they are advanced, when victims reach “a point of no return,” said Dr. Vincent Iacopino, a senior medical adviser to Physicians for Human Rights. Unable to absorb calories, many do not recover without sophisticated medical care, even if given the food portions of others, he said.

Regardless, aid workers say, the fact that military blockades are preventing people in such acute need from receiving aid is in itself a human-rights violation. It matters little, they say, whether those suffering are technically the first victims of incipient famine, something no organization has the access or data to determine, or simply sick people who need treatment.

“It shouldn’t have to take people starving to support these people,” said another aid worker.

The very unlikelihood of hunger in Syria galls those suffering from it. “It’s very strange to know that the food is only five minutes away from you,” said Qusai Zakarya, a spokesman for a rebel council in Moadhamiya, who said he recently spoke on the phone to a friend who was eating a cheeseburger in the wealthy neighborhood of Mezze just a few miles away.

Syrian Arab Red Crescent workers and residents say that signs at checkpoints around Moadhamiya and other Damascus suburbs read, “Kneel or starve.” One Red Crescent volunteer said in a Skype interview that a soldier at a checkpoint recently told him that he would desert the army sooner than follow any order to allow food in to “the ones who are shooting us.”

But civilians suffer, too. Sawsan, 33, a widow in rebel-held Hajar al-Aswad, said in a Skype interview that her family, including a child with kidney failure who has not had dialysis in six months, has “an eating rotation — not everyone eats every day.”

Abu Hazem, 43, a taxi driver in Moadhamiya, said he fed his five children a dwindling supply of lentils, sometimes mixed with grass, and once shot a dog for food “because there are no birds flying over Moadhamiya.” The children no longer cry from hunger; they are used to it, he said. “They start singing sometimes when they are hungry.”

Umm Hamza, who fled Moadhamiya with her two children and gave only a nickname for fear of reprisals, described eating mainly greens after her stores of pickled food ran out and a rebel-run bakery closed for lack of flour and fuel.

“We spent days with no water and no food at all,” she said in a recent interview near a government shelter in Qudsaya, her face yellowish and her eyes weary. She said she knew several people who had lost children for want of food and medicine.

Moadhamiya has gone without meat, eggs and milk for months, and in August, after pasta stocks ran out, leaving mainly olives, leaves and greens, people started to die, Mr. Zakarya said. He provided medical reports and videos.

First there was Ammar Arafa, 8, a disabled child who lived mainly on the formula PediaSure, which, like his medications, became unobtainable. Then Ibrahim Khalil, 4, his limbs skin and bone. Imad Sawan, 5, was wounded during shelling and recovered poorly from a bowel operation, a procedure that requires extra nutrition to heal. A similar fate befell Mona Ragab, 30.

Rana Obaid, the grocer’s daughter, Mr. Zakarya said, lived her first months in a house of roses — real ones in the courtyard outside, and inside, the fabric flowers that Moadhamiya was long known for producing. The family was not wealthy but lived decently, with a motorbike and enough money to give to the poor.

Born small and weak, Rana eventually grew normally, even after her family’s house was shelled and they moved to a relative’s abandoned apartment. Yet after months without protein or formula, Rana grew thin and sick, eventually unable to swallow olives, her family’s main food.

By September, her arms and legs were bone-thin. She was filmed lying on a makeshift hospital table, her bright eyes briefly fixing the camera with an intense gaze as a doctor gently palpated her bloated stomach, her prominent ribs, her bleeding gums. A subsequent shot showed her still, stick-figure corpse.

“My dear daughter, she was like a ghost. I felt helpless,” Abu Bilal, who has a surviving 7-year-old, told Mr. Zakarya recently. “But I feel relief now. I know she’s with her God and feels peace. There is no hunger there. There is no cold, and no shelling.”

Mohammad Ghannam contributed reporting from Beirut, and an employee of The New York Times from Qudsaya, Syria.

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