(CNN)In a single week, eight of Rob Freishtat's tiny patients died of hunger.
In his photos, the children already seem to be vanishing, dwarfed by diapers three times their girth and the thick gloved hands of medical staff. Small comforts on their hospital beds, like the rolls of baby blankets printed with cheerful ducklings make them look even tinier.
All were under 2 years old when they died.
"Over the years, I've seen plenty of kids in Haiti with malnutrition get sick with infections or something else and die. Sad but not unusual. This is the first time that I have seen them literally starve to death," Freishtat told CNN after returning from a week at Sacre Coeur private hospital in the northern Haitian city of Milot, in early December.
Freishtat is the chief of emergency medicine at Children's National Hospital in Washington, DC, and he has volunteered his pediatric skills in Haiti every year for the past decade, ever since a devastating earthquake hit the Caribbean nation on January 12, 2010.
Now, just days ahead of the 10-year anniversary of that disaster, Haiti's population appears little prepared to face the next major shock, with millions threatened by hunger in 2020 due to a spiraling economic and political crisis.
Official mortality statistics for 2019 have not yet been made public, but doctors and medical staff working across the country tell CNN that unusually high levels of malnourishment are already claiming the country's most fragile lives -- and that more deaths are expected in the coming months.
Food insecurity headed for 'emergency levels'
Haiti has been on a rollercoaster of good intentions since the 2010 earthquake. Attention and donations from the rest of the world spiked in the immediate aftermath of the 2010 earthquake -- and then dropped. A deal with Venezuela known as PetroCaribe temporarily provided the country's government with cheap fuel, but then foundered and became linked to a scandal over the alleged mismanagement of the resulting funds.
Basic public services like hospitals and food access are supported by international aid organizations (which come with their own set of problems), but more and more Haitians simply cannot afford the food they need. According to the UN disaster relief organization OCHA, the cost of the most basic, joyless kitchen essentials in Haiti -- rice, wheat flour, maize, beans, sugar and vegetable oil -- jumped 34% this year alone.
"Marasmus (the medical term for starvation) was uncommon in Haiti since most families previously could afford rice or sugary drinks. That is no longer the case," said Freishtat.
In the poorest country in the Western hemisphere, a 25 kilogram bag of rice costs about $23 -- a steep increase over 2017 and 2018. (Though inflation can vary wildly level across different regions.)
"The under-2 group of kids is particularly vulnerable because formula is exorbitantly expensive there. Breastfeeding would be great, but the moms are starving too, so their milk dries up," he adds.
According to a new report by OCHA, things will only get worse. Forty percent of Haitians will face food insecurity by March, the agency predicts. For least 1 in 10, food insecurity will reach "emergency levels."
A national lockdown
Since 2018, Haitian protestors have been calling for change, their fury over the country's economic path fueled by official reports alleging massive corruption. But the resulting clashes have sometimes taken a toll on fellow citizens.
This fall, Haitian protesters demanding President Jovenel Moise's resignation pulled a desperate lever: peyi lock, a countrywide lockdown. Barricades were erected on roads across the country, some with as little as a kilometer between them, some manned by armed men. But the strategy failed to pressure Moise out of office, and further choked the country's flailing economy and emergency services.
Between fuel shortages and blocked roads, medical workers struggled to send supplies to rural areas, including vital flows of blood and oxygen to hospitals. Outbreaks of violence, including reported gang attacks, forced many schools to close down -- cutting off essential distribution points of food aid for kids.
One November evening during peyi lock, a young woman in labor with twins arrived at a small maternity hospital in the south, recounts Sandra Lamarque, the head of the Belgian mission of Doctors without Borders in Haiti. She urgently needed specialized obstetric care.
The facility did not have a specialist on hand, so it contacted a nearby general hospital, which refused to accept her. A second hospital said it no longer had a gynecologist, and a third said that because it had been looted and vandalized twice in October, it no longer saw patients after 6 p.m., Lamarque recounts, speaking from the southern coastal city of Port à Piment where the maternity hospital is located.
A fourth facility, a private clinic, finally agreed to see the woman, but wanted payment of $400 -- in a country where half the population lives on less than $2 per day. "The patient was taken care of and this is a happy ending, but if MSF had not made the transportation, contact with all hospitals -- and paid -- she would have died," said Lamarque.
Lamarque worries that, as inflation rises, even the medicines and services to save Haiti's hungry and injured will go up in price. According to local media, inflation drove up the cost of drugs and hospital services by about a third in 2019.
The number of mothers dying in childbirth was "extremely high" this year, she adds -- and that's only counting women who made it to hospitals to begin with. At least 45 women died in Haiti's southern region in 2019, Lamarque said -- more than anywhere else in the country, and a 35% increase over last year.
2019's long tail
By December, protester' barricades had been lifted, but the deadly aftereffects of the year's troubles are expected to extend into the new year. Ominously, there's no sign of political resolution on the horizon.
The children being hospitalized now are in a sense the country's canaries, the earliest victims of a danger to which the state can offer little response.
"There's always a delay between the nutritional state and the crisis ... so a rising death toll is expected," said Cédric Piriou, Haiti director of NGO Action Against Hunger, speaking to CNN from the capital Port au Prince.
Institutions that should nurse Haiti back to relative health in periods of calm have been crippled, with some hospitals remaining closed or understaffed. And while health services in the country are more developed and wider spread than they were before the 2010 earthquake, Piriou and other medical staff interviewed by CNN emphasize that the country is in no condition to deal with another major disaster.
"There isn't blood or oxygen in hospitals. It's been worse in these past three months," Piriou said, adding that other services like orphanages and prisons are also faltering. Haiti's Ministry of Public Health did not respond to multiple requests from CNN for comment.
Piriou, a Bréton who has worked in the country for two decades, has been personally touched by the crisis -- his wife's cousin, he said, had to go to two Haitian hospitals when she gave birth because the first one had no blood. Her child died within 24 hours.
Even without another major disaster, Haiti's hospitals could soon see a new wave of children suffering from the accumulated effects and complications of months of hunger, predicts Freishtat, the pediatrician.
"First you see the little babies, then you're going to start to see the bigger kids," he said.