BISSAU, Guinea-Bissau — The most heartbreaking thing about starving children is their equanimity.
They don't cry. They don't smile. They don't move. They don't show a flicker of fear, pain or interest. Tiny, wizened zombies, they shut down all nonessential operations to employ every last calorie to stay alive.
We in the West misunderstand starvation — especially the increasing hunger caused by the global economic crisis — and so I've been traveling across five countries in West Africa, meeting the malnourished.
At the extreme, they were like Maximiano Camara, a 15-month-old boy here in Bissau, who was so emaciated that he risked failure of major organs. His ribs protruded, his eyes were glassy, his skin was stretched taut over tiny bones.
(Doctors try to help but are overwhelmed: One was showing me Maximiano when a nurse rushed in from another room carrying a baby who had stopped breathing. The doctor paused, revived that child on the next bed, handed her back to the nurse, and then calmly resumed his discussion of Maximiano.) Even if Maximiano survives, hunger may leave him physically stunted. Or poor nutrition may have already withered the development of his brain.
It's impossible to know if Maximiano was starving because of the economic crisis or because of chronic malnutrition here, but the hardships in the developing world have been exacerbated by elevated food prices and declining remittances from workers abroad.
The World Bank has estimated that U.N. goals for overcoming global poverty have been set back seven years by the global crisis.
It calculates that increased malnutrition last year may have caused an additional 44 million children to suffer permanent physical or mental impairment.
Yet one of the great Western misconceptions is that severe malnutrition is simply about not getting enough to eat. Often it's about not getting the right micronutrients — iron, zinc, vitamin A, iodine — and one of the most cost-effective ways outsiders can combat poverty is to fight this "hidden hunger."
Malnutrition is not a glamorous field, and so it's routinely neglected by donor governments, poor countries and journalists. But malnutrition is implicated in one-third to one-half of all child deaths each year; the immediate cause may be diarrhea, but lurking behind it is a deficiency of zinc.
"That image of a starving child in a famine doesn't represent the magnitude of the problem," notes Shawn Baker of Helen Keller International, a New York-based aid group working in this area.
"For every child who is like that, you have 10 who are somewhat malnourished and many more who are deficient in micronutrients.
"Lack of iron is the most widespread nutrition deficiency in the world, and yet you can't really see it," he added.
Recently I wrote about women dying in childbirth. One reason so many die of hemorrhages is that 42 percent of pregnant women worldwide have anemia, according to the World Health Organization.
Here in Guinea-Bissau, 83 percent of youngsters under age 5 suffer from iron deficiency. An American or European typically has a hemoglobin, or Hb, level of 13, while anemic women and children in Africa are sometimes at 5 or below.
"In Europe, we get worried when Hb drops to 9, and then we consider a transfusion," said Dr. Annette Kroeber, a German working at a Doctors Without Borders clinic for malnourished children in Sierra Leone. "Here, when we get Hb up to 6, we're very happy."
The general rise in food prices (in part because of American use of corn for ethanol) is leading to more micronutrient deficiencies.
One study found that a 50 percent rise in food prices in poor countries leads to a 30 percent drop in iron intake.
One solution is to distribute supplements to vulnerable people, or to fortify foods with micronutrients. A panel of prominent economists produced the "Copenhagen Consensus" on which forms of aid are most cost-effective, and it ranked micronutrient supplements as No. 1 (malaria prevention was No. 12, sanitation No. 20).
Americans typically get micronutrients from fortified foods, and the same strategy is possible in Africa. Helen Keller International is helping Guinea's leading flour mill fortify its products with iron, folic acid and vitamin B (zinc is coming soon). We visited the mill, and managers said that the fortification costs a tiny fraction of a penny per loaf of bread — yet it will reduce anemia, maternal mortality and cognitive impairments around the country.
None of this is glamorous, but it's hugely needed — and truly a bargain.
THE NEW YORK TIMES NEWS SERVICE