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‘There’s a path towards death that people travel’: how hunger destroys lives and communities | Global development

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The human body is smart, says Dr Christopher Mambula, medical manager for east Africa at Médecins Sans Frontières. He’s talking about the physical effects of food deprivation, a subject that gets little attention even within the medical world, and yet, as aid agencies continue to report, affects hundreds of millions of people around the world. “If it doesn’t have enough food to convert into energy,” he continues, “it will burn through its own fat reserves, breaking down fat cells into fatty acids to be used for energy or converted into glucose by the liver.”

How long it takes for the body to use up all its fat deposits depends on multiple factors: the amount and nutritional value of food being eaten; the individual’s metabolism; their activity levels; their body mass index; and their age and overall health.

“It could take a month, six months, a year. People don’t go from some food to zero food. They start to reduce the number of meals. In places like the Horn of Africa people may go entire days without a meal,” Mambula says.

After a sustained period of severe lack of food, the only fat left in the body will be between muscles, in joints and organ cells. “In women, in the worst-case scenario, you will notice they have no more breast tissue because every single ounce of fat is converted in places that are usually spared,” Mambula says.

While this is happening, low glucose levels in the blood make the person feel weak and dizzy. It is at this point – feeling woozy, irritable and struggling to concentrate – that many people are forced to make difficult decisions. If they cannot find water for their cattle, do they sell it at a vastly lower price than its original worth? Do they take their daughters out of school? Do they split up the family?

Woman has arm measured during food WFP distribution in Adale, near Gode in Ethiopia on 6 April
A woman has her arm measured as the World Food Programme distributes food in Adlale, near Gode in Ethiopia, 6 April. Photograph: Eduardo Soteras/AFP/Getty Images

Using up the body’s fat reserves is not dangerous in itself, but if food deprivation continues once the fat is gone, the body will start to break down muscle cells to access the fatty acids and proteins contained within them. The result of this is muscle atrophy – the medical term for loss of muscle mass – as the muscle cells lose their structural integrity. Within a few weeks, there’s no longer enough muscle to support the body, even in a seated position. Lying down is the only option.

As muscle cells break down they release chemicals, including potassium, chloride and sodium, and cellular debris into the bloodstream. These chemicals, combined with a lack of vital minerals and vitamins from malnutrition, cause an imbalance that affects multiple parts of the body, from individual cells to organ function. Lack of zinc can cause diarrhoea and cracked skin, and reduces the ability to fight infections. Salt imbalance may be associated with oedema or swelling, which can also lead to kwashiorkor, or severe malnutrition in young children, causing swollen bellies and faces.

Dr Neal Russell, a paediatric adviser with MSF, says: “There is a path towards death that people travel. Until they are at a late stage, deficiencies can be corrected by giving food, but beyond a certain point the body cannot regulate itself, even with treatment.”

The last thing to stop is the heart – in some cases, because the weakened heart is simply not powerful enough to pump blood around the body; in others, chemical imbalance in the bloodstream stops the heart. A person may not be conscious at this point: unable to function without energy, the brain begins to shut down. In the last hours before falling into a coma, a person may lose their vision as the brain zones in and out.

Though malnutrition affects millions of people, especially children, there is still much that is unknown about it. “Much of what we thought we knew 20 years ago has since been questioned,” Russell says.

Abdi Ibrahim, who is malnourished, is helped by his wife, Duba Dagane, in Lagbogal, 56km from the town of Wajir in Kenya
Abdi Ibrahim, who is malnourished, is helped by his wife, Duba Dagane, in Lagbogal, Kenya. Photograph: Sayyid Azim/AP

Lack of money means there is still a dearth of research into both the short- and long-term impacts of malnutrition. “This is not a subject that people put a lot of medical research into,” he adds. “The money is in obesity and overnutrition, and research follows money. We got Covid vaccines in one year.”

What is known is that most people suffering from malnutrition die from disease or infection rather than starvation itself. Lack of food affects the immune system, shrinking the lymph nodes so they produce fewer white blood cells. The existing white blood cells don’t have sufficient energy to do their job in fighting off bacteria or healing a wound. A person is much more vulnerable to diseases such as malaria or conditions such as pneumonia and sepsis.

A dystopian crisis

“Zero hunger” by 2030 was one of 17 sustainable development goals set out by the UN in 2015. Today, the UN predicts that the number of people affected by hunger will surpass 840 million by 2030. Far from the situation improving, millions are trapped in the worst hunger crisis in living memory. The World Food Programme says 50 million people in 45 countries are teetering on the edge of famine.

“A few years ago, things were gradually getting better and now it is going in the other direction, rapidly. It’s extremely worrying when you think about the impact on real people. What shocks me is the lack of outrage – it’s horrifying,” Russell says.

In September, the UN warned that famine was likely to be declared in Somalia later this year.

A letter to UN member states as they gather for the 2022 UN general assembly this week was the latest call for immediate funding to prevent suffering now and in the future. “In a world of plenty, leaving people to starve is a policy choice,” reads the letter, which is signed by 238 NGOs. “The lack of political will and institutional failure to act quickly before the worst case hits means people are being left to lurch from crisis to crisis. People are not starving; they are being starved.”

Kallayn Keneng, right in the foreground, sits with other women in Lekuangole, South Sudan. All the women have lost children after they were displaced by fighting.
Kallayn Keneng (right, in the foreground) with three other women who lost children to starvation after they fled fighting in their village, Lekuangole, South Sudan. Keneng, 40, says she watched two of her young children die. Photograph: Sam Mednick/AP

These are needless deaths that will be largely ignored by a world distracted by extreme weather, the cost of living crisis and political upheavals. Aid agencies have the knowledge and ability to address food insecurity, but not the funding, says Alexandra Rutishauser-Perera, head of nutrition at Action Against Hunger UK. “We know how to [address food insecurity] better and better, but we are not given the means to implement all we know. Aid is not arriving fast enough and is not large enough to improve the situation. For the moment, it’s about trying to reduce the number of lives being lost.”

In addition to lack of funding, costs are rising. Over the past year, the cost of ready-to-use therapeutic food (RUTF) that Action Against Hunger gives to malnourished children has increased by 23%, including a 9% increase since the war in Ukraine began. According to Unicef, global prices for RUTF are expected to increase by an additional 16% over the next six months, as the price of transportation and ingredients continues to rise.

The war in Ukraine has pushed up the cost of food, energy and fertiliser around the world, and caused supply chains to stall, adding to the existing strain from conflict, extreme weather and economic shocks.

Russell describes watching this crisis unfold before his eyes as “dystopian”. He feels a responsibility to communicate what hunger does to people, but struggles to find the right words. “I can go into my safe zone [using medical terminology], but I have never found the language to describe the horror and injustice of seeing a child dying from malnutrition.”

Children aged around eight stand beneath a chalk line that shows how tall their age group should be, at Betesda primary school in Bemanonga, near Morondava in Madagascar
Children of about eight years old stand beneath a chalk line that shows how tall their age group should be, at Betesda primary school in Bemanonga, near Morondava in Madagascar. A teacher at the school said 70-80% of children are malnourished and often miss class as a result of diarrhoea. Photograph: Kate Holt/WaterAid

In 2021, MSF admitted 82,000 children to intensive therapeutic feeding centres, a 27% rise on 2020. A further 200,000 children were treated for malnutrition outside hospital. It expects numbers to grow again in 2022.

“One of the most haunting things about a children’s malnutrition centre is the deadly quiet of some children,” Russell says. “Their childhood has evaporated away. Young children regress, and stop walking or become incontinent – and they stop doing normal things like playing.”

Globally, malnutrition underlies almost half of child deaths in under-fives. The majority will die of infection because their immune systems are battered by lack of nutrients. “Your general defences against infection are reduced, your skin becomes thinner, your gut wall is thinner, the defences in your respiratory tract are weaker [and] less likely to cough things up,” Russell says.

Measles, malaria, pneumonia and diarrhoea are all common killers among children suffering from malnourishment; in many cases these children are moderately, as opposed to severely, malnourished. “The malnutrition can be just enough to tip the balance in children, causing them to contract an infection that will kill them.”

For every 10 children admitted to an intensive therapeutic feeding centre, one will probably die. Research published in the Lancet in May 2022 suggests that for every one that dies in hospital another will die after they are discharged.

A woman holds her malnourished daughter at a clinic in Tigray, northern Ethiopia.
A woman holds her malnourished daughter at a clinic in Tigray, northern Ethiopia. Photograph: Ben Curtis/AP

The first 1,000 days of life are crucial for nutrition. Children who survive can suffer long-lasting effects. Impaired cognitive and physical and behavioural development can affect their education. The condition is also intergenerational – an adolescent girl or young woman who is undernourished may give birth to an undernourished baby.

The hidden mental health cost

For every child too weak to laugh or play, there is a shellshocked mother and father watching on helplessly. A study published in the National Library of Medicine found the prevalence of moderate to severe depression among mothers of malnourished children was significantly higher (64.1%) compared with mothers of normal weight children (5.1%).

But there is little funding to address mental health in areas where hunger kills and tears families apart. “I’ve seen what it does to a family but we are not given enough money for it. The impact of providing water, food, medicine can be measured but it’s really difficult to account for mental health provision to a donor, so it is always the first thing to be cut [if there is not enough funding],” says Rutishauser-Perera.

Yemeni Nasser Ahmad al-Qallam and his granddaughter gather to eat boiled leaves near their house at the mountain village of Bani al-Qallam, about 100km south-west of Sana’a, Yemen
Nasser Ahmad al-Qallam and his granddaughter gather to eat boiled leaves near their house in the mountain village of Bani al-Qallam in Yemen, in February 2021. Six years of civil war have pushed many to the brink of starvation, destroying cattle and crops. Photograph: Yahya Arhab/EPA

“When you don’t have the money to have psychologists onboard, agencies don’t have the means to identify and measure the extent of the problem, and offer appropriate support,” she adds.

In addition to the stress of not being able to provide, the breakdown of relationships between families also depletes a person’s mental reserves. As part of its work, Action Against Hunger helps mothers to bond with their children who survive illness, teaching them to play with children who did not have the energy to interact while they were ill.

“Hunger takes something away from you,” Russell says. “You can see how that breaks down a society and leads to more insecurity, conflict and anger.”

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The Netherlands: Nicaragua’s Daniel Ortega escalates diplomatic crisis with US and Europe | International

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Nicaraguan President Daniel Ortega.
Nicaraguan President Daniel Ortega.JAIRO CAJINA (AFP)

Nicaraguan President Daniel Ortega has decided to break ties with the Netherlands in what is the latest diplomatic feud to be sparked by the former guerilla. The Nicaraguan Foreign Ministry said in a statement on Friday that it had severed all diplomatic ties with the European country because it “offended and keeps offending Nicaraguan families.”

The decision to break ties was made after the Dutch ambassador for Central America, Christine Pirenne, informed the Nicaraguan government that the Netherlands would not be funding a $21.5 million hospital promised long ago. The news outraged Ortega, who accused the ambassador of treating Nicaragua as if it were “a Dutch colony.”

“Those who come to disrespect our people, our homeland, they should not appear again in Nicaragua. And we do not want relations with that interventionist government,” he said during his speech on Friday, which marked the 43rd anniversary of the founding of Nicaragua’s repressive National Police. “We [the Sandinista government] continue to open hospitals, even when we are met with human misery. The human misery of a European country, the Netherlands!” he added.

Diplomatic sources told EL PAÍS that the Netherlands had suspended the hospital project due to the “mishandling of funds, lack of transparency, and the serious human rights situation in Nicaragua.”

“The Netherlands regrets the disproportionate decision by Nicaragua to break off diplomatic relations. We take a firm stand on the worsening democratic structures and human rights violations in Nicaragua,” Dutch Foreign Minister Wopke Hoekstra said via Twitter on Saturday. “Other countries have also noticed difficulties in maintaining an open dialogue with Nicaragua. We will discuss our next steps with the EU.”

The clash with the Netherlands followed a week of heightened tensions with the European Union and the United States.

On Friday, Nicaragua’s Vice President Rosario Murillo, the wife of Ortega, also announced that the Central American country would not accept the new US-appointed ambassador Hugo Rodriguez as its representative in Managua. Ortega initially signed off on the appointment, but withdrew his support in July after Rodriguez told the US Senate Foreign Relations Committee that he would continue to advocate for an end of human rights violations in Nicaragua.

“The United States has spoken out against these abuses, and, if confirmed [as ambassador], I will continue to do so, not because we have any intention to determine Nicaragua’s internal affairs, but because it is our commitment under the Inter-American Charter, which both the United States and Nicaragua signed in 2001,” Rodriguez told the committee.

Despite Nicaragua’s objections, the Joe Biden administration appointed Rodriguez as ambassador on Thursday. Ortega railed against the decision during his speech to police forces. “The candidate for ambassador to Nicaragua appeared before the Senate, and what did he do? He insulted and disrespected us,” he said on Friday. “So we immediately said ‘get out, get out and stay out, and he can continue yelling whatever he likes out there, but here in our country, our flag is respected.’”

On Thursday, in another speech, Ortega attacked the Vatican, Chilean President Gabriel Boric and Brian Nichols, White House Assistant Secretary of State for Western Hemisphere Affairs, who he described as a “poor Black man” with a “bulldog face.” Boric and other Latin American leaders, who have called for the release of political prisoners, were branded as “lapdogs” of the United States and the European Union.

And on Wednesday, Nicaragua declared the European Union ambassador, Bettina Muscheidt, “persona non grata” and gave her three days to leave the country. The decision was made after the EU delegation demanded freedom for Nicaragua’s political prisoners at the United Nations General Assembly last week.

“The EU profoundly regrets and rejects this unjustified and unilateral decision,” the European External Action Service (EEAS) said in a statement released on Sunday, a day after Muscheidt left Nicaragua. “The EU also profoundly regrets the disproportional and unjustified unilateral decision taken on Friday by the Nicaraguan government to cut diplomatic ties with the kingdom of the Netherlands and expresses its unwavering support to the Dutch government,” it added, warning that it would respond in a “firm and proportional manner.”

In recent months, Nicaragua has also rejected all proposals for dialogue, including those put forward by Pope Francis, Colombian President Gustavo Petro and the US government.

“Ortega’s strategy is to escalate the crisis to a point where only the use of force will solve it, but he knows very well that the use of force is not an option the international community is going to consider,” Eliseo Núñez, a former opposition deputy in Nicaragua, told EL PAÍS. “Everyone believed that they could push Ortega to the brink of the abyss, but he has taken the international community to that brink and is forcing it to choose between two options: a global economic blockade, which would collapse Nicaragua, or to sit back and wait to see what happens.”

Some analysts believe that Washington is seeking to exhaust all diplomatic routes with Nicaragua via Ambassador Rodriguez in order to justify future action against the country, such as expelling it from the DR-CAFTA free trade agreement.

“Ortega has been using vulgar, racist and blasphemous rhetoric,” Arturo McFields, Nicaragua’s former ambassador to the Organization of American States (OAS), told EL PAÍS. “It is a narrative that is aligned with Russia’s foreign policy. Right now, Russia is facing NATO, the United States and the European Union. Ortega is sticking in a parasitic way to the foreign policy of Moscow and China.”

McFields recalled that Nicaragua was one of the seven countries that did not want the president of Ukraine, Volodymyr Zelenskiy, to appear remotely at the United Nations General Assembly. “I believe that in the next few days, Ortega is going to break diplomatic relations with other countries in the European Union,” said McFields.

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Afghans left in legal limbo in Greece while ‘real refugees’ helped to settle | Migration and development

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It is 3.30pm and Suna Hamanawa, 25, is doing what she and dozens of other Afghan mothers do most days: whiling her time away on a park bench in Viktoria Square, a scruffy plaza in central Athens, as her children play around her. Like almost every other asylum seeker, she is relieved to be in Greece.

“We’re better here, we’re safer here even though me and my husband and our first little one [initially] spent 10 months in Moria,” she says, screwing up her face at the memory of the notoriously overcrowded and fire-ravaged refugee camp on Lesbos.

“But every day, in its own way, is a fresh hell. The Greek government does nothing. It just keeps saying ‘wait, wait, wait’. And that’s what we do all day, every day. Wait for our papers, wait for our travel documents. Wait for freedom.”

A year after Afghanistan’s fall to the Taliban, Greece continues to be the first port of call for thousands of people fleeing the country’s worsening humanitarian crisis. After Ukrainians, Afghans account for the second-largest group of asylum applicants in the EU and by far the biggest in Greece, where more than 37,000 – more than a third of the total number registered nationwide – have filed asylum claims.

Hamanawa, who arrived in Lesbos with her husband, Mohammed, in a dinghy from Turkey in 2018, waited four years to become one of the estimated 28,500 Afghans to secure refugee status – a protracted period of legal limbo that is vastly at odds with other refugees, not least those from Ukraine.

In a recent report, the International Rescue Committee (IRC) chronicled Afghan refugees’ difficulties in Greece and the serious impact on their physical and mental health.

Of the 192 Afghans monitored by the organisation’s mental health teams between April 2021 and March 2022, about 97% had reported symptoms of depression, while 50% had considered suicide, the IRC report said.

“Many Afghans fleeing conflict and persecution in their own country think their troubles will be over once they reach Europe … This is simply not the case,” says Dimitra Kalogeropoulou, the IRC’s Greece director.

“Instead, people face the stark reality of violent pushbacks from Greek borders, months or years living in fear of being sent back to Turkey or Afghanistan, where they could face untold horrors, extended periods trapped in prison-like reception conditions, far from towns and cities and an alarming lack of support to begin rebuilding their lives,” she says.

For the estimated 70,000 Ukrainians who have sought refuge in Greece, it has been a different story. After Russia’s invasion on 24 February, the EU moved quickly to issue a temporary protection directive to safeguard the rights of people desperate to leave the war-torn country.

Although relatively few Ukrainians have headed to Greece, the reception they have received there has been unusually warm, with senior officials often referring to the newcomers as “real refugees”.

It was vital, said the IRC report, that Afghans were also guaranteed access to full and fair asylum procedures and given “dignified” support with accommodation and integration.

“While the Greek government has welcomed refugees from Ukraine, by efficiently registering them, issuing legal documents and allowing immediate access to employment, Afghans in Greece, alongside other asylum seekers and refugees, continue to be isolated from the Greek society in which they seek to rebuild their lives,” the report’s authors wrote. “Even after receiving status, refugees have limited integration support.”

Afghan asylum seeker Khorshid Ahmadi and her daughter Leyla in Viktoria Square, Athens.
Khorshid Ahmadi, an Afghan refugee, and her daughter, Leyla, in Viktoria Square, Athens. Photograph: Helena Smith

The biggest barrier for Afghans claiming asylum is the Greek government’s controversial decision to label Turkey a “safe third country” for people not only from Afghanistan but also from Bangladesh, Pakistan, Somalia and Syria. The decision has prevented thousands of people from being able to explain why they need international protection.

“We’ve been here for four years,” says Khorshid Ahmadi, 26, as she plays with her children in Viktoria Square. “My family’s request for asylum has been rejected three times. They keep saying we should return to Turkey, even if Turkey doesn’t take anyone back from Greece.”

As a result, she says, neither she, her husband nor their five children have legal status or any right to housing or cash assistance.

Greece’s centre-right government insists it pursues a “tough but fair” migration and asylum policy. Accusations of pushbacks – despite overwhelming evidence – have been strongly denied. But keeping asylum seekers at bay remains a priority. In September, the migration minister, Notis Mitarachi, noted that the country had blocked about 50,000 migrants from entering Greece in August alone.

Amid renewed tensions with Turkey, the public order minister in Athens claimed last month that every night about 1,500 people gathered at the land border with Turkey were attempting to cross as a result of Ankara’s policy to “weaponise” migration and push asylum seekers into Greek territory.

As one of Europe’s most southerly states, Greece was the main entry point for more than 800,000 Syrians when the refugee crisis first engulfed the continent in 2015. After the adoption of a controversial pact aimed at stemming flows between the EU and Turkey in March 2016, the influx dropped steeply.

As patrols have been reinforced, with the help of the EU’s border agency Frontex, the number has fallen further in recent years, particularly arrivals on the north Aegean islands facing the Turkish coast, where most asylum seekers at the height of the crisis were located. The decline prompted the Greek prime minister, Kyriakos Mitsotakis, to boast last week that smuggling networks had been largely cracked.

International bodies have echoed the IRC in rebuking Athens for resorting to tactics of brute force to keep asylum seekers out.

Concluding a 10-day fact-finding tour of Greece in June, Mary Lawlor, the UN special rapporteur for human rights defenders, accused the Mitsotakis government of creating a “climate of fear”, not only for refugees and asylum seekers fleeing poverty and persecution but also for groups defending migrants’ rights on the ground. Illegal evictions of asylum seekers at land and sea borders had become a general policy in Greece, she said.

Last week, Mitarachi insisted the government would continue to replace open-air camps on frontline islands, such as Lesbos, with barbed-wire encircled “closed controlled” access centres, and would push ahead with plans to extend a border fence along the Evros land frontier with Turkey.

Mohamad Mirzay, Greece’s Afghan community spokesperson, who arrived in the country in 2006 at the age of 14, says: “Every day, we hear from families back home of Afghans being lost at the border.

“One of our biggest problems is that a lot of young Afghans whose asylum claims are rejected get into drugs, a problem we are now trying to address as a community. It’s all so very hard. Very few want to stay here, they don’t want to endanger their future. For sure, you could say, Ukrainians get very different treatment.”

Sofia Kouvelaki, who heads the Home project, an NGO that supports unaccompanied minors, said: “Ukrainian refugees have proved a point. In Greece, and in the EU, they have shown that if we want to integrate we can, and if we want to welcome people with a human face we can do that too.”

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Opposition Party of Bulgaria’s Ex-Prime Minister Borisov Leading in Parliamentary Vote

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MOSCOW (Sputnik) – Opposition party Citizens for European Development of Bulgaria (GERB), chaired by former Prime Minister Boyko Borisov, is coming ahead in the snap parliamentary elections, Bulgaria’s Central Election Commission said after processing over 51% of the ballots.

The GERB and Union of Democratic Forces coalition currently has 25.64% of the votes, while the centrist We Continue the Change (PP) party, co-led by former Prime Minister Kiril Petkov, is second with 20.87%.

In June, the Bulgarian parliament cast a vote of no-confidence in the coalition government and the cabinet led by Prime Minister Petkov was forced to resign. Attempts to form a new government failed.

Bulgaria held three snap parliamentary elections last year, as no party was able to form a government. In November 2021, lawmakers finally formed a four-party coalition between PP, the Bulgarian Socialist Party, There Is Such a People (ITN), and Democratic Bulgaria, ending a month-long government crisis. The elections saw an all-time low turnout of less than 40%.



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