More than 130,000 children aged under five died in the famine in Somalia in 2011, a study says.
A decision by extremists Islamist militants to ban food aid and a "normalisation of crisis" that numbed international donors to unfolding disaster made south-central Somalia the most dangerous place in the world to be a child in 2011.
The first in-depth study of famine deaths estimates that 133,000 under-fives died, with child death rates approaching 20% in some communities. There are an estimated 6.5 million people in south-central Somalia.
That compares to 65,000 under-five deaths that occurred in all other industrial countries in the world during the same period, a combined population of 990 million, said Chris Hillbruner, a senior food security adviser at FEWS NET, a US-sponsored famine warning agency.
"The scale of the child mortality is really off the charts," Mr Hillbruner said.
The new study put the total number of famine deaths at nearly 260,000. The Associated Press first reported the death toll on Monday, based on officials who had been briefed on the report.
FEWS NET was one of two food security agencies that sponsored the study. The other was the Food Security and Nutrition Analysis Unit - Somalia. The two agencies had warned the world as early as fall 2010 that failed rains in Somalia meant a hunger crisis was approaching.
In March 2011 some 13,000 people died from famine, the study found. In May and June 30,000 people died each month - at least half of them children. The UN's formal declaration of famine didn't happen until July.
Why was there such a slow humanitarian response? One reason Mr Hillbruner indicated was the feeling that Somalis are always suffering.
"I think that one of the key issues is that there was this normalisation of crisis in south-central Somalia, and that I think the international community has become used to levels of malnutrition and food insecurity in southern Somalia that in other parts of the world would be considered unacceptable," he said.
The study was conducted by Francesco Checchi, an epidemiologist at the London School of Hygiene and Tropical Medicine, and Courtland Robinson, a demographer at Johns Hopkins University.
Philippe Lazzarini, the chief UN humanitarian co-ordinator for Somalia, said in a video news conference from Mogadishu that the death toll was shocking and sobering. He said the report confirms that aid groups should have done more before famine was declared - by which point 120,000 people had already died.
Mr Lazzarini also noted that more than a dozen aid groups were banned from operating in south-central Somalia by the extremist Islamist group al-Shabab, a hardline anti-West political decision that made saving lives "extraordinarily difficult".
He said that in the months before famine was declared the crisis did not receive the amount of attention it should have, in part because of a lack of access because of al-Shabab.
Thousands of Somalis walked dozens or hundreds of miles to reach camps in Kenya, Ethiopia and Mogadishu, the Somali capital. Countless numbers of families lost children or elderly members along routes that became known as roads of death.
Somalia has made great progress since the famine ended in February 2012. Al-Shabab has been forced out of Mogadishu and now controls far less territory than it once did.
The government appears more capable than the Transitional Federal Government in place during the famine, but challenges like child mortality and food security remain.