SAN CASIMIRO, Venezuela — Kenyerber Aquino Merchán was 17 months old when he starved to death.
His father left before dawn to bring him home from the hospital morgue. He carried Kenyerber’s skeletal frame into the kitchen and handed it to a mortuary worker who makes house calls for Venezuelan families with no money for funerals.
Kenyerber’s spine and rib cage protruded as the embalming chemicals were injected. Aunts shooed away curious young cousins, mourners arrived with wildflowers from the hills, and relatives cut out a pair of cardboard wings from one of the empty white ration boxes that families increasingly depend on amid the food shortages and soaring food prices throttling the nation. They gently placed the tiny wings on top of Kenyerber’s coffin to help his soul reach heaven — a tradition when a baby dies in Venezuela.
When Kenyerber’s body was finally ready for viewing, his father, Carlos Aquino, a 37-year-old construction worker, began to weep uncontrollably. “How can this be?” he cried, hugging the coffin and speaking softly, as if to comfort his son in death. “Your papá will never see you again.”
Hunger has stalked Venezuela for years. Now, it is killing the nation’s children at an alarming rate, doctors in the country’s public hospitals say.
Venezuela has been shuddering since its economy began to collapse in 2014. Riots and protests over the lack of affordable food, excruciating long lines for basic provisions, soldiers posted outside bakeries and angry crowds ransacking grocery stores have rattled cities, providing a telling, public display of the depths of the crisis.
But deaths from malnutrition have remained a closely guarded secret by the Venezuelan government. In a five-month investigation by The New York Times, doctors at 21 public hospitals in 17 states across the country said that their emergency rooms were being overwhelmed by children with severe malnutrition — a condition they had rarely encountered before the economic crisis began.
“Children are arriving with very precarious conditions of malnutrition,” said Dr. Huníades Urbina Medina, the president of the Venezuelan Society of Childcare and Pediatrics. He added that doctors were even seeing the kind of extreme malnutrition often found in refugee camps — cases that were highly unusual in oil-rich Venezuela before its economy fell to pieces.
For many low-income families, the crisis has completely redrawn the social landscape. Parents like Kenyerber’s mother go days without eating, shriveling to the weight of children themselves. Women line up at sterilization clinics to avoid having children they can’t feed. Young boys leave home and join street gangs to scavenge for scraps, their bodies bearing the scars of knife fights with competitors. Crowds of adults storm Dumpsters after restaurants close. Babies die because it is hard to find or afford infant formula, even in emergency rooms.
“Sometimes they die in your arms just from dehydration,” Dr. Milagros Hernández said in the emergency room of a children’s hospital in the northern city of Barquisimeto, noting that the hospital had started seeing an increase in malnourished patients at the end of 2016.
“But in 2017 the increase in malnourished patients has been terrible,” she added. “Children arrive with the same weight and height of a newborn.”
Carlos Aquino weeping over the casket of his son, Kenyerber, who died of heart failure caused by severe malnutrition.
Before Venezuela’s economy started spiraling, doctors say, almost all of the child malnutrition cases they saw in public hospitals stemmed from neglect or abuse by parents. But as the economic crisis began to intensify in 2015 and 2016, the number of cases of severe malnutrition at the nation’s leading pediatric health center in the capital more than tripled, doctors say. This year looks even worse.
In many countries, extreme malnutrition “can be caused when there is war, a drought, some sort of catastrophe or an earthquake,” said Dr. Ingrid Soto de Sanabria, the chief of the hospital’s nutrition, growth and development department. “But in our country it is directly related to the shortages and inflation.”
The Venezuelan government has tried to cover up the extent of the crisis by enforcing a near-total blackout of health statistics, and by creating a culture in which doctors are often afraid to register cases and deaths that may be associated with the government’s failures.
But the statistics that have come out are staggering. In the Ministry of Health’s 2015 annual report, the mortality rate for children under 4 weeks old had increased a hundredfold, from 0.02 percent in 2012 to just over 2 percent. Maternal mortality had increased nearly fivefold in the same period.
For almost two years, the government did not publish a single epidemiological bulletin tracking statistics like infant mortality. Then in April of this year, a link suddenly appeared on the Health Ministry’s official website, leading to the unpublished bulletins. They showed that 11,446 children under the age of 1 had died in 2016 — a 30 percent increase in one year — as the economic crisis accelerated.
The new findings made national and international headlines before the government declared that the website had been hacked, and the reports were swiftly removed. The health minister was fired and the military was put in charge of monitoring the bulletins. No reports have been released since.
Doctors are censored in hospitals, too, often warned not to include malnutrition in children’s medical records.
“In some public hospitals, the clinical diagnosis of malnutrition has been prohibited,” Dr. Huníades Urbina said.
But doctors interviewed by The Times at nine of the 21 public hospitals said that they had kept at least some count. They encountered nearly 2,800 cases of child malnutrition in the last year alone, with starving children regularly brought to emergency rooms. Nearly 400 of the children died, the doctors said.
“Never in my life had I seen so many hungry children,” said Dr. Livia Machado, a pediatrician who gives free consultations at her private practice to children who had been hospitalized at Dr. Domingo Luciani Hospital in the capital, Caracas.
The hospital is one of the few still accepting malnourished infants for treatment. Other hospitals often turn them away, telling desperate parents that they do not have enough beds or medical supplies to treat their children. Nearly all of Venezuelan hospitals report shortages of basic provisions like baby formula.
President Nicolás Maduro has acknowledged that people are hungry in Venezuela, but he has refused to accept international aid, often saying that Venezuela’s economic problems are caused by foreign adversaries like the United States, which he says is waging an economic war against his country.
Venezuela has the largest proven oil reserves in the world. But many economists contend that years of economic mismanagement set the stage for the current disaster. The damage was masked when oil prices were high, giving the government large resources. But when oil prices began a steep fall at the end of 2014, scarcities became common and food prices skyrocketed. Inflation could reach 2,300 percent next year, the International Monetary Fund warned in October.
The Health Ministry and the National Institute of Nutrition did not respond to requests for interviews or official health reports containing malnutrition statistics. But the nation’s political opposition, which has been stripped of its power by the government, continues to sound the alarm.
“We have a people who are dying of hunger,” Luis Florido, a congressman who leads the National Assembly’s foreign policy committee, told lawmakers in November, calling the food crisis “a humanitarian emergency that all Venezuelans are living.”
‘So Many Children’
Kenyerber was born healthy: 6 pounds 7 ounces. But his mother, María Carolina Merchán, 29, was bitten by a mosquito and infected with a severe case of the Zika virus when Kenyerber was 3 months old. She had to be hospitalized, and doctors instructed her to stop breast feeding because of serious complications from her illness.
Unable to find or afford infant formula, the family improvised with whatever they could find: bottles of cream of rice or cornstarch, mixed with whole milk. It did not provide Kenyerber with the nutrients he needed.
At 9 months, his father found him listless in bed, with blood running from his nose. He rushed him to the overcrowded pediatric emergency room at Dr. Domingo Luciani hospital, where patients and beds spill out of rooms, into dingy hallways paced by armed soldiers.
Kleiver Enrique Hernández, 3 months old, was being treated for severe malnutrition a few beds down from Kenyerber. He too was born healthy — 8 pounds 2 ounces — but his mother, Kelly Hernández, could not breast-feed him, either.
Again, despite searching endlessly, Ms. Hernández and her boyfriend, César González, could not get infant formula for their son. It was not for lack of trying.
In online inventory searches of Locatel, one of the largest pharmacy chains in Venezuela, The Times found that only one of its 64 locations across the country reported having the infant formula doctors had prescribed for Kleiver in stock.
It is unlikely that Ms. Hernández could have afforded it anyway. Hyperinflation has shriveled wages paid in the local currency, bolívars, to a small fraction of what they were worth two years ago. A month’s worth of the formula Kleiver needed cost more than twice the entire monthly salary that Mr. González earned as an agricultural worker.
Formula shortages hit the hospitals, too. Doctors in the emergency room at Dr. Domingo Luciani hospital said they had no formula in stock to feed patients like Kenyerber and Kleiver. The 2016 National Survey of Hospitals found that 96 percent of Venezuelan hospitals reported not having all of the infant formula they needed to attend to patients. More than 63 percent reported having no formula at all.
With so few options, Kleiver’s mother warily prepared bottles of rice starch and water, occasionally with whole milk, when they could find it. It was not enough.
Sisters and cousins of Kelly Hernández holding her up at the wake for her 3-month-old son, Kleiver, in August.
Children carrying Kleiver’s coffin during his funeral procession.
Friends and family gathering in the early morning hours at Kleiver’s wake.
His parents had taken him to three emergency rooms. Each hospital was full. “I was desperate — and seeing so many, so many children in the same situation as our boy,” Ms. Hernández said.
When they were admitted to Dr. Domingo Luciani, they were tremendously relieved. But soon they watched a steady stream of parents arriving with malnourished babies — only to leave, crying, “My child has died!”
They waited anxiously for Kleiver’s condition to improve, sleeping in a chair by his side or in the courtyard outside, on alert to go searching for any supplies the doctors might ask for.
After 20 days in the hospital, they became one of the families they had watched in horror. A team of doctors worked for hours to help Kleiver, inadvertently covering him in blood and bruises as they tried to insert a tube into his neck. By the time doctors finally accepted that they could not save him, his lifeless body looked brutally beaten. Kleiver had suffered an incredibly painful death, his doctors said — one that they said could have been avoided had infant formula been available.
Severe acute malnutrition is both self-evident and strikingly complex. Even when doctors are open to recording it for a patient, it is not necessarily the official cause of death. Instead, acute malnutrition can set off a range of pathologies in the human body, leading to death from respiratory failure, infection or other ailments. But in the case of Kenyerber and Kleiver, a rare situation occurred for Venezuela: Severe malnutrition was listed as a cause of death on their death certificates.
More than 100 friends and family members came to the all-night wake in Kleiver’s family home. His aunts and cousins hung large posters decorated with colorful hand-drawn cartoons and messages. Kleiver lay underneath, in a small white coffin, on paper wings.
Just three months earlier, the family had colored signs and tacked them to the walls — to celebrate his birth. One still hung over his bed the night of his wake, cut into the shape of a balloon.
“Welcome Kleiver Enrique, I love you so much,” it said.
After the sun came up, the neighborhood held a large funeral procession to the cemetery. Ms. Hernández collapsed on a nearby tombstone, sobbing uncontrollably. Overcome by the guilt of not being able to breast-feed or find infant formula for her son, she shouted repeatedly, “Am I an awful mother? Please, just say it!”
Helpless and Indignant
In Barquisimeto, Dr. Hernández rushed into the emergency room, shouting: “I’m coming in with an 18-day-old baby. He was fed with anise tea, cow’s milk and sometimes breast-fed by a neighbor. It’s a bad one!”
Doctors and nurses at Dr. Agustín Zubillaga University Hospital of Pediatrics worked quickly to assess the baby, Esteban Granadillo. He weighed 4 pounds 10 ounces, and looked scared, fixing his hollow eyes on the doctors outside the thick plastic walls of his incubator.
“Tell me what you gave him to eat,” Dr. Hernández asked the boy’s great-aunt, María Peraza, who had taken him to the hospital. “This child’s stomach was destroyed and possibly even his liver by what you fed him!”
Children suffering from malnutrition occupied four of the 12 beds in the pediatric emergency room that day in August. Doctors there said they had received malnutrition cases nearly every day — a rarity until the crisis started getting worse two years ago.
But only a fraction of the medicines they need are available. In June, the hospital director at the time, Dr. Jorge Gaiti, said he had requested 193 necessary medications from the government agency responsible for distributing them to public hospitals. Only four of the 193 were delivered, according to the reports visible on his computer. The hospital even lacks the most basic medical supplies — soap, syringes, gauze, diapers and latex gloves.
Nurses send parents away with lists of items to look for in pharmacies or to buy from the black-market vendors who circle the hospital, selling exorbitantly priced, hard-to-find medical supplies.
Dr. Hernández said she felt indignant and helpless as a doctor, as children died in her emergency room unnecessarily. “It is unfair,” she said.
At 18 days old, Esteban Granadillo was taken to Dr. Agustín Zubillaga University Hospital of Pediatrics with severe malnutrition.
Dayferlin Aguilar, a 5-month-old girl diagnosed with malnutrition and dehydration, was treated at Dr. Agustín Zubillaga University Hospital of Pediatrics in August.
Esteban’s mother was single, disabled and unable to breast-feed him, his great-aunt said. In desperation, relatives had asked a neighbor with a young child to step in and breast-feed. The family also fed him bottles of cow’s milk, or chamomile water and anise tea, to fill his stomach.
“We could not find formula anywhere,” said Ms. Peraza, the great-aunt, acknowledging that she knew the food could hurt the baby. “Yes, it was bad, but I tell you — if we had not done it, this baby would have died.”
Ms. Peraza stayed at the hospital next to Esteban’s incubator for days, stroking his stomach through the openings and whispering softly to him. He spent weeks in and out of the hospital — and died on Oct. 8.
Three floors above, pediatricians examined a 1-month-old baby, Rusneidy Rodríguez, a week after she was admitted for severe malnutrition. Her mother, hospitalized with an infection, had been unable to breast-feed her. As in Esteban’s case, her relatives had been unable to find formula, so they made bottles out of what they could find: whole milk, cream of rice, or water mixed with barley — an ingredient used to make beer.
The emergency room was so overwhelmed that gurneys overflowed into the hallway. Sometimes the hospital has to double up patients, two per bed.
In the incubator next to Esteban, a 5-month-old girl, Dayferlin Aguilar, struggled to open her eyes and smile at her mother, Albiannys Castillo. Ms. Castillo had brought Dayferlin to the hospital when the little girl became very weak, falling in and out of consciousness and suffering uncontrollable diarrhea. Doctors diagnosed malnutrition and dehydration.
Ms. Castillo could not produce any breast milk, so she routinely arrived at 1 a.m. to wait in line outside pharmacies until they opened, to search for infant formula. More often than not, she said, they had none in stock or would run out by the time she got to the front of the line.
“Your mamá is here with you, my daughter — and I love you,” she told Dayferlin when the little girl managed to open her eyes.
Dayferlin died three days after being admitted to the hospital. She was buried with fuchsia-colored wings made from paper, trimmed in turquoise, with a matching crown placed on her head.
Digging Through Garbage
Oriana Caraballo, 29, waited in line for hours with her three children — Brayner, 8; Rayman, 6; and Sofia, 22 months — to enter a crowded soup kitchen run by a local Roman Catholic church in Los Teques. Aside from drinking water, they had not eaten for three days.
Before the crisis, Ms. Caraballo fed her children using the wages from her job at a restaurant. Now she wept as she spooned soup into Sofia’s mouth — and recounted how her children had foiled her suicide attempt.
Ms. Caraballo could not bear the pain of watching her children go hungry. She said she had taken them outside her home, while her baby daughter was sleeping, then went back inside and shut the door. She hung a cable and wrapped it around her neck, she said. When she was just about to hang herself, she heard her daughter start to cry.
“I heard a voice tell me, ‘Do it, do it, do it,’” she said. “Then in my other ear I heard, ‘Don’t do it, don’t do it — look at your children.’”
Her son called to her, telling her to open the door. She became overcome with guilt and decided against suicide. Her oldest son has fainted several times at school, from going without breakfast or dinner the night before. He cries every night because he is hungry and, at 8, begs his mother to let him work to buy food for the family.
Families scavenging for food scraps from garbage bags in Caracas, an uncommon sight before the economic crisis worsened.
Oriana Caraballo feeding her children, Brayner, Rayman and Sofia, at a soup kitchen in Los Teques in September.
A recent report by the United Nations and the Pan American Health Organization found that 1.3 million people who used to be able to feed themselves in Venezuela have had difficulty doing so since the economic crisis began three years ago.
In soup kitchens around the country visited by The Times, many of the parents who brought their children had full-time jobs. But hyperinflation had destroyed their salaries and savings. A 2016 survey by three Venezuelan universities found that nine out of 10 households had become “food insecure” in Venezuela.
Caritas, the Roman Catholic aid group, has been weighing and measuring groups of children under 5 in working-class communities in multiple states since last year. Fifty-four percent of children in them suffer from some sort of malnutrition, the study has found.
Many families scavenge for food in the streets or at garbage dumps. Few are homeless, and most said they had never had trouble finding food before the crisis. Hundreds of people can be seen picking through garbage cans each evening when restaurants, grocery stores and residential buildings take out their trash for collection.
In the coastal town of Morón, dozens of people waded knee-deep in garbage at a large dump, looking for food and recyclables to sell. The nearby port in Puerto Cabello was once the driving force behind the local economy. Now it is largely empty.
Many of the people picking through the trash at the dump said that they used to work in the port but were now desperate to feed their families after being laid off once ship traffic slowed to a trickle. Several mothers said they had never imagined having to feed their families from discarded garbage.
Families are also increasingly sending their children into the streets to beg, or to work for money for food. Some never returned.
Turning to the Streets, or Sterilization
In Caracas, two brothers — José Luis Armas, 11, and Luis Armas, 9 — said they had run away from home, where there was scarcely enough to eat. Now they live in the streets with other homeless boys in street gangs, getting into knife fights to expand or defend their territories and to control areas for panhandling or picking through garbage for recycling.
Several of their friends have been killed, they said. Luis raised his shirt to show a large gash across his stomach — the result, he said, of a machete attack by a member of another gang. The attack nearly killed him, he said.
They say they prefer to live on the streets, despite the danger, because they eat better than they could living at home with their families. They spend their days panhandling, searching for discarded food and recyclables, bathing in public fountains, stashing their belongings in trees and storm drains, while constantly avoiding run-ins with the police and rival gangs.
Nelson Villasmil, a government social worker in the capital, said that before the crisis, most of the homeless children he encountered lived in the streets because of parental negligence or abuse. But now when he interviews them, he says, they often tell him they left their homes because there was no food to eat.
“What they cannot find in their houses, they go to find in the street,” Mr. Villasmil said.
Three months ago, Yail Fonseca, 13, said he left his home in Los Valles del Tuy to search for food in Caracas.
“I left my home because things are hard,” he said. “We weren’t eating well.”
He says he eats better as a homeless person on his own in the capital than at home with his family on the outskirts of the city. He sleeps under an overhang at an outdoor skate park with a group of other homeless adults and children, waking up at 6 a.m. to search through garbage for food or beg for handouts from local restaurants.
In the evenings, he says, he practices sparring with other young members of his gang, using sticks to become more agile at knife fights. His leader requires them to practice at least 30 minutes a day.
The gang leader, an adult who would not reveal his full name, said they had a code: If anyone in the gang is attacked by a single member of a rival gang, he must defend himself alone, even to the death, no matter how old he is. The rest of the gang will step in only if a member is attacked by multiple rivals at once. Four young members of the gang had been stabbed to death in recent months, the leader said. The boys around him lifted up their shirts to show their own scars.
Sometimes the state steps in, taking away children from some homes where hunger is common. After two of their children died of complications from malnutrition, Nerio Parra and Abigail Torres lost three more — to social workers.
Women waiting to be surgically sterilized at a free event at a government-run hospital in Caracas in July.
Families lining up at a free children’s health clinic in Morón in September.
Eduardo José Martínez, 13, at the skate park in Caracas where he lives with other homeless children and adults.
Their 7-month-old daughter, Nerianyelis, died in September 2016 when the family could not find infant formula for sale, they said. Mr. Parra had a full-time job at a company that makes labels, but the couple said they could afford to feed their children only once a day. The morning Nerianyelis died, she was sluggish and very thin. Her parents said they had carried her in the rain to the hospital, to no avail.
Abigail was so distraught that she broke down and refused to let go of her daughter’s body, they said. Hospital security had to forcibly separate the two. Then on Dec. 1, 2016, their 5-year-old son, Neomar, who suffered from malnutrition, dehydration and other ailments, died as well, his case worker said.
After Neomar died, social services took away the three remaining children and placed them in group homes. Now, the couple visit their surviving children and go to the cemetery to visit the graves of their deceased ones.
The burden of caring for children in Venezuela can be so great these days that many women are opting to be sterilized. Just after dawn one Saturday in July, 21 young women dressed in surgical gowns waited to be surgically sterilized during a free event at the state-run José Gregorio Hernández Hospital in a working-class neighborhood of the capital.
The hospital says it has sterilized more than 300 women through this program. On that Saturday, all 21 of the women, who ranged from 25 to 32 years old, said they already had children and wanted to be sterilized because the economic crisis had made it too difficult to raise children. Each feared becoming pregnant again, citing dire shortages of essential supplies like diapers, formulas, milk and medicine.
The crisis has also led to widespread shortages of birth-control pills and condoms. Many of the mothers at the sterilization event said that their most recent pregnancies had been unplanned and unwanted, but that they did not have access to birth control.
Eddy Farías, 25, a hair stylist, said she was nervous about the operation but resolute in her decision to undergo it. As a single mother with a full-time job, she said her wages at a salon were barely enough to feed her five children.
“It’s hard to be a mom,” she said. “If your child gets sick, you have to run circles trying to find a hospital,” she added. “It is a war just to survive day to day.”
After her operation, she said, she was in pain from the large incision across her lower abdomen, but relieved.
“If I got pregnant again, that would mean I’d have to go to war again for diapers,” she said. “It is like war to have to buy diapers on the black market, or have to wake up before dawn to wait in long lines and fight others for the food, the diapers, the personal things a child needs.”
Skipping Meals So Her Children Can Eat
Six weeks after cutting out angel wings from the food rations box to bury Kenyerber, his family was still battling hunger.
His mother, María Carolina Merchán, said she had wilted to 66 pounds from skipping meals so that her four surviving children had a little more to eat. Government social workers said she was severely malnourished, as were her own mother and her 6-year old daughter, Marianyerlis. The family has gone as long as five days at a time without consuming anything besides water.
Marianyerlis follows Ms. Merchán around for hours, wailing and sobbing, begging for food. Ms. Merchán stares blankly at the floor as tears roll down the little girl’s cheeks.
“Mama, I’m hungry!” she cries.
Her weight fluctuates between 20 and 29 pounds, depending on how much food she is able to get. The Centers for Disease Control and Prevention lists 6-year-old girls who weigh less than 35 pounds in the lowest fifth percentile. Marianyerlis recently fainted after going two days without eating.
The family have made their home with relatives in an abandoned government housing project, with no running water or indoor plumbing, and jury-rigged electricity. It is uncomfortable, but all of their income must be spent on food.
Kenyerber’s mother, María Carolina Merchán, right, weighs just 66 pounds. Her daughter follows her for hours, begging for food.
Baby portraits of the children, one of their few cherished belongings, hang prominently on the wall. The only food in the entire house is half a bag of salt, and one lime.
“This is a nightmare,” said Ms. Merchán’s sister, Andreína del Valle Merchán, 25, describing how the children start to vomit, sweat and become sluggish after days of not eating. Her own 5-year-old daughter had lost 11 pounds this year and now weighed only 17 pounds, she said.
The suffering of Venezuelan families is expected to worsen next year. Beyond the I.M.F.’s warning that inflation could surpass 2,300 percent, observers worry that the leftist government will continue to refuse international aid for political reasons.
“If they accept the help, they accept that there is a humanitarian crisis here, and officially recognize that their population is vulnerable, and just how much their policies failed them,” said Susana Raffalli, a specialist on food emergencies who consults for Caritas in Venezuela.
The Venezuelan government has used food to keep the Socialists in power, critics say. Before recent elections, people living in government housing projects said they were visited by representatives of their local Socialist community councils — the government-aligned groups that organize the delivery of boxes of cheap food — and threatened with being cut off if they did not vote for the government.
Kenyerber’s relatives do not expect the economic crisis to improve anytime soon. They fear that another child in the family may die as well.
“I worry about it day and night,” said his aunt, Andreína.
(c) The New York Times