A baby with acute malnutrition receives care at a hospital in Somalia, where thousands of refugees are seeking famine relief. (ROBERTO SCHMIDT/AFP/GETTY IMAGES)

Two years of drought have left millions of people facing starvation in the Horn of Africa — more than 4 million in Somalia alone. Tens of thousands have died, and an estimated 750,000 are at risk of death.

About 36 percent of Somali children under the age of 5 are malnourished; nearly 16 percent are severely malnourished, according to that country’s Food Security and Nutrition Analysis Unit.

“It took me a week to say those malnutrition rates without having the hairs on my arm stand on end,” said Peter Hailey, a nutrition specialist with UNICEF in Somalia, in a phone interview. “In 20 years, I’ve never seen rates so high.”

The staggering numbers are not only challenging the resolve of responders to the crisis. The numbers are also the biggest test yet of recent improvements in assessing and treating malnutrition, changes that range from the coordination of care to the ingredients of food aid.

Less than a decade ago, almost all refugees arriving at a camp would go to large — but not large enough — hospitals.

Strategies have shifted, however, and in most camps refugees now start at a reception center. Workers there provide food, water and vaccinations, and they perform triage — assessing levels of malnutrition and diagnosing other conditions.

The most ill of the refugees are sent to a hospital for inpatient care, while those who are only mildly ill are sent into the camp itself and asked to visit one of many outpatient centers for occasional checkups.

“Before, we’d have 10,000 people headed toward a hospital, but you can’t run a hospital with 10,000 people,” said Susan Shepherd of Doctors Without Borders in Nairobi in a phone interview. “With [outpatient] treatment, we’ve been able to get to people earlier and better allocate resources.”

Part of ensuring the right care for the right people is objectively determining the level of malnutrition. For children from 6 months to 5 years old — the ages most vulnerable to the effects of malnutrition — workers at a reception center will measure a child’s height and weight and compare those to standards from the World Health Organization. A 3-foot-tall boy, for example, should weigh a little over 29 pounds; when severely malnourished, the boy might weigh 23 pounds or less. Workers can also measure the circumference of a child’s mid-upper arm; less than 115 millimeters — about 41 / 2 inches, a little less than the circumference of a golf ball — indicates severe malnutrition.

A test of appetite is also done, because children often lose their appetite when severely malnourished. If the child eats, he’s probably only moderately or mildly malnourished.

Hospitals then focus on the most dire cases of malnutrition.

Treating malnutrition

In images of the crisis, we see a few of the symptoms of severe malnutrition: emaciation, distended stomachs, fatigue and glazed eyes.

Without food, the body resorts to consuming its own tissue, said Nigel Rollins, a WHO pediatrician. A lack of nutrients can cause cellular damage that prompts water and other fluids to gather in tissue, particularly around the limbs. The abdomen might also swell because of an accumulation of fat in the liver.

“The body slows itself down and goes into energy-conserving mode to maintain function,” Rollins said. The heart pumps less blood, the kidneys filter out less waste and the liver breaks down fewer toxins than normal. After a while, the liver and kidneys can become so weak that food is a danger all its own: It might actually overwhelm the body’s ability to filter toxins and nutrients.

Hypoglycemia and hypothermia are also concerns with malnutrition, but the effect that can be most dangerous is a weakening of the immune system. When nutrients such as vitamins A, C and E become depleted, a condition akin to AIDS called Nutritionally Acquired Immune Deficiency Syndrome can develop.

“They’re more vulnerable to disease, and disease hits harder,” Saskia van der Kam of Doctors Without Borders said, referring to people with severe malnutrition. Measles, gastroenteritis, pneumonia and cholera become major threats.

When a severely malnourished patient arrives at a hospital, doctors will spend the first few days preventing infections and providing essential nutrients and electrolytes. Later, treatment becomes focused on rebuilding tissue and regaining energy.

Esther Sterk, a medical coordinator with Doctors Without Borders, has been working during the crisis at a hospital in the Dagahaley camp in Dadaab, Kenya. With 7,000 children being cared for at outpatient facilities, Sterk and her team have been able to focus on the 150 or so children in need of 24-hour care.

“It’s overwhelming,” Sterk said of life in the hospital during a phone interview, “but we’re managing, especially with the [outpatient facilities] increasing access to treatment.”

Among those in Sterk’s care at the time were a mother and her four children, ages 2 to 7. When the family arrived, “the children were traumatized,” Sterk said. The three youngest were not only severely malnourished, but they had developed pneumonia as well. Two also had gastroenteritis, or stomach flu, which can lead to severe diarrhea.

Once in Sterk’s care for a few days, the children improved dramatically, thanks to a course of antibiotics, vitamins, fluids and specialized, therapeutic foods.

Improving food aid

Food aid, like medical care, has taken dramatic steps forward in recent years. Oils, beans, rice and corn are now complemented by much more targeted, nutritionally dense foods.

“Previously, a lot of food was designed for the average child, but now we’re much more focused on what the child needs to be brought back to normal body composition and growth rate,” said Rebecca Stoltzfus, director of the Program in International Nutrition at Cornell University.

Research over the past decade has revealed the importance of zinc, calcium and Vitamin D, among other nutrients, Stoltzfus said. Researchers also now understand the need not just for proteins but also for a full array of amino acids, the building blocks of proteins.

Scientists are placing greater emphasis on ease of consumption, too, as exemplified by the peanut-butter-based Plumpy’nut. Part of a growing category of ready-to-use therapeutic foods, Plumpy’nut has made an “enormous difference,” according to Werner Schultink, UNICEF’s chief of nutrition. The paste is ready for consumption — no water, cooking or other ingredients necessary — and it’s densely nutritious, consisting of vegetable fat, skimmed milk powder and various vitamins and minerals.

Plumpy’nut “tastes like the inside of a Reese’s peanut butter cup,” Stoltzfus said, noting that palatability is indeed an important factor in food aid: “When you lose your appetite, you become much pickier about what you eat, so you want to have something that the children will like to eat.”

Strides are also being made among supplementary foods, which are provided to the general population of refu­gee camps to ensure they meet baseline levels for certain nutrients. Typical rations including beans and rice might not be adequate, so foods such as Nutributter — a pasty mixture that contains peanuts, sugar, vegetable fat and whey — and Plumpy’doz, a variation on Plumpy’nut, can help prevent further malnutrition. Neither food requires cooking.

Other read-to-use supplementary foods are in the pipeline, including a corn-soy blend developed by Charles Onwulata, a food researcher with the U.S. Department of Agriculture. Corn-soy blends are cereal-like mixtures and have long been a standard provision for food aid. Refugees have had to add water and herbs, however, before eating.

“I’ve been on the move and understand that you don’t have time when running away from bullets to cook,” said Onwulata, who was born in Nigeria and lived through that country’s famine in the late 1960s.

Many major advancements have been made in aid responses since then, and experts expect many more as the current famine crisis passes and more come along.

“We’re still on a learning curve,” Stoltzfus said of dealing with malnutrition. “We’ve been able to protect more people from death, but there’s still more new science to come.”