Famine and Infectious Disease

General starvation increases susceptibility to numer­ous pathogens. Conversely, infection accelerates the course of general starvation. This process is en­hanced as declining health and increased mortality add to social disorder, creating greater impediments to the acquisition of food, increased Undemutrition, and conditions ripe for the spread of disease.

This vicious circle can originate on the side of ei­ther pathogenic illness or Undemutrition. Epidemic disease has the potential for ushering in general starvation, especially if infections debilitate or kill a large number of food producers. This is most liable to occur when a new disease is introduced into a region whose inhabitants have no acquired immunity. Many native American populations suffered severe famine upon first exposure to such commonplace Old World illnesses as measles and smallpox. Generally speaking, however, it is more often the case that infectious epidemics follow in the wake of starvation. The diseases that become epidemic tend to be famil­iar ones, long endemic to a region. Virtually any endemic illness has epidemic potential during fam­ine, but certain of them have become notorious.

In the Western world, those diseases most disposed to reach epidemic proportions have been typhus, re­lapsing fever, smallpox, dysentery, tuberculosis, bu­bonic plague, influenza, and pneumonia. Changes affecting public health have altered the epidemic potential of these diseases at various points in his­tory. Thus, typhus (famine fever, spotted fever), a Iousebome infection that for centuries had been Eu­rope’s most dreaded famine disease, ceased to be a concern among most undernourished groups during World War II owing to the widespread use of DDT. However, with the disappearance of typhus, epi­demic tuberculosis, which almost certainly had been present but undetected in previous famines, became a major problem.

As for the East, experience with famine-related epidemics has been much the same as that of Eu­rope, with some exceptions. Typhus has not been seen in well-watered tropical and Semitropical re­gions where people are accustomed to bathing daily. In contrast, waterborne disease such as dysentery and cholera have become virtually synonymous with mass starvation in such climates. Typhoid epidemics have been associated with famines in China. Acute malaria and heavy hookworm infestations have been observed in famished populations of India.

In Africa the effects of malaria do not appear to be aggravated by general starvation. However, con­trary to experience in the rest of the Old World, including India, recent episodes of general starva­tion in Ethiopia, Nigeria, and the Sahel have been accompanied by epidemics of measles extremely le­thal to children. Yet judging from records of the Great Ethiopian Famine of 1888-92, the greatest of all African famines, epidemic measles has not al­ways been a problem in Africa in times of dearth. More common have been epidemics of cholera, small­pox, meningitis, dysentery, and pneumonia, and ty­phus outbreaks have also been reported in Ethiopia.

Two factors, often working together, facilitate the occurrence of epidemics under famine conditions. The first is loss of community resistance to the spread of infection, and the second is loss of individ­ual immune competence.

Loss of community resistance can be accounted for by a number of phenomena. These include popula­tion dislocations and the overcrowding of public fa­cilities, both of which destroy barriers to the spread of infections. Transmission is further abetted by the behavioral economies that accompany inanition and xmdermine domestic hygiene and public sanitation.

Loss of community resistance is clearly illustrated in the case of typhus. Normally confined to isolated pockets of stark poverty, typhus often broke out over vast areas of Europe during starvation winters when a massive number of people, lacking energy and wrapped in thick layers of clothing to combat hypothermia, found it increasingly difficult to bathe or wash their clothes.

Starvation can undermine individual resistance at virtually every line of bodily defense. As protein is lost, protective anatomic surfaces such as skin and mucous membranes lose integrity as barriers against the invasion of pathogens. Flaky skin le­sions, intestinal atrophy, and a reduction in tissue­healing capacity, frequently observed in children suffering from chronic protein-energy malnutri­tion, facilitate infection.

Once inside the body, infective agents encounter an impaired immune system. On the cellular side of this system, starvation has ill effects on both phagocytes and T-lymphocytes as the former lose efficiency as bacteria killers and the formation of the latter is depressed. On the humoral side, the comple­ment system, a group of proteins that interact to form substances for the destruction of bacteria and viruses, functions poorly in undernourished chil­dren. Immimoglobulins, protein molecules secreted by B-lymphocyte-derived plasma cells and a princi­pal element of the humoral immune system, are often found in serum at high levels among mal­nourished populations. Reflecting the high incidence of infection that such populations experience even in the best of times, the buildup of immunoglobulin levels in children is especially rapid. Despite this, when confronted with certain antigens, including the pathogens of typhoid, influenza, mumps, diphthe­ria, and yellow fever, the immunoglobulins appear hypoactive.

Nutritional balance is adversely affected by a num­ber of reactions to infection. These include higher caloric expenditure resulting from greater mobiliza­tion of protein due to increased stress and adrenocor­tical activity; decreased food intake owing to general malaise, increased secretion of mucus, and appetite loss; and intestinal changes leading to reduced ab­sorption of ingested foods. With regard to energy expenditure, relatively little is known beyond the fact that, if infection involves fever, basal metabo­lism increases. Nevertheless, it is suspected that even in the absence of fever virtually all infections increase the demand on energy sources. The effects of illness on protein nutrition have received a great deal of attention. Protozoal and helminthic diseases such as malaria and hookworm have adverse affects on nitrogen balance proportional to parasitic load. Most bacterial and viral infections have negative effects on nitrogen balance. Bacterial and viral infec­tions of the intestinal tract are of major significance in most developing countries where diarrhea consti­tutes a major disease, particularly in infants and young children. Intestinal infections impair the ab­sorption of nitrogen, but more significant in creating a nitrogen imbalance is an abnormally high excre­tion of that element in urine, much of this coming from an increased breakdown of muscle tissue. Con­siderable nitrogen is also lost through fever-induced sweating. Making up for nitrogen loss is difficult given the decline in appetite that typically accompa­nies intestinal illness.