The Silent Killer in Northern Nigeria: Implications and Challenges in Addressing Malnutrition

BY AASTHA KC

Imagine a child whose survival is challenged even before it is born. Imagine a child whose mother was shot in the chest while escaping a terrorizer from Boko Haram and has ended up at the hospital not because of her gunshot wounds but because her child is malnourished.  Such is the story of Kaswey, a young mother in the the Borno state in northern Nigeria, whose life has been torn apart as insurgents have taken down schools, military establishments, villages and health clinics¹. Worse, these violent actions have limited transactions for agricultural activities, destroyed crops and fields leaving Kasawey and 5 million Nigerians vulnerable to an inevitable famine in northern Nigeria¹. Furthermore, over 2.5 million of the 13 million children in Nigeria who are stunted live in the Borno state and the International Rescue Committee, a relief-aid humanitarian organization estimates that more than 205 of them will die if proper actions are not taken¹. 

Furthermore, the health sector in the Borno state and in northern Nigeria  have been severely damaged. Insurgents have destroyed over 700 health facilities, killed over 48 health care workers and injured another 250¹. Due to the instability of the region, health care worker attrition has dropped to 35% and access to health care resources have been limited¹. Boko Haram’s insurgency has sent shockwaves of political, social and health instability not just in the northern regions but throughout Nigeria. It has lead Mr.Yakubu Dogara, the speaker of the House of Representatives to declare a state of emergency “on the menace of malnutrition in Nigeria, especially the north-east,” in October of 2017⁵. 

Malnutrition is a public health emergency that requires severe attention from the federal government as Nigeria is one of the countries with the highest malnutrition in the world^3,11. To understand the challenges faced by children under five suffering from malnutrition, it is important to explore the underlying political and social instabilities in Nigeria, especially in the rise of extremists groups such as Boko Haram¹¹. Tensions between Boko Haram and the Nigerian Armed Forces have displaced over 3.3 million Nigerians from their land and severely limited their access to food and health services^1,9. 

Despite the rise in political uncertainty and health instability, Nigeria should aim to meet the targets and goals set forth by the Sustainable Development Goal 2, which seeks to “end hunger, achieve food security, improve nutrition and promote sustainable agriculture². Specifically, target 2.2 which aims to “end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women will be explored in this paper². In the context of the goals put forth by SDG 2, malnutrition in children under five in Nigeria is a multifaceted challenge that can be approached by exploring the underlying causes and implications of malnutrition while aiming to provide soundful recommendations based on existing intervention programs and strategies. 

Causality analysis: Factors leading to malnutrition 

Labeled as a “silent killer” because it often goes unnoticed, malnutrition, which refers to the improper uptake of nutrients in children, has negative health effects for children especially during the first 1,000 days of life⁴. The World Health Organization recognizes this as an important “window of opportunity” to ensure the livelihood of the child into his or her adult life⁴. Being malnourished in the first 1,000 days of life can result in poor brain and body development, weaken the immune system and increase chances for infectious diseases such as diarrhoea and pneumonia^4,8,11. For Nigeria, the United Nations Population data predicts that over a half-million children die every year due to malnutrition³. 

Although by definition, malnutrition is caused by a lack of nutrients, the underlying causes build on social, economic and structural inequalities⁷. Poverty combined with a lack of economic and social mobility is the leading cause of malnutrition in Nigeria. Due to politicians receiving kickbacks from giant oil companies such as Shell and Eni, wealth has not been directed to public programs and has resulted in an increase in the number of  people living in extreme poverty⁶. Extreme poverty as defined by those living on less than $1.90 per day has actually increased in Nigeria from 51 million in 1990 to 86 million in 2013 leaving more individuals vulnerable to food and housing insecurity, low economic mobility and decreased access to education and health services^4,11. 

Extreme poverty has a multitude of  negative effects for children. A child in a poor family is 3.5 times as likely of being underweight than a child in a higher income household³. Poorer households may not have enough money to buy sufficient nutritious food and may have trouble sustaining a continued supply of food⁴. Lower income households are more sensitive to economic changes and are affected by inflation rates more intensely than higher income households due to spending the greatest proportion of their income on buying staple foods⁸. In 47% of surveyed households in Daura in the Kistina state in northern Nigeria, agriculture production was found to account for less than 25% of the total household food consumption⁸. The remainder of the households diet comes largely from buying food in local markets and food received for work. Poorer families also own fewer livestock and survive through a combination of smallholder agriculture, casual labour and petty trade⁸. 

Overall, agriculture in Nigeria has remained on a small-scale subsistence level and is largely inefficient due to crop seasonality, inadequate storage technology and inadequate transportation systems. The spatial and seasonal variation in food production and availability further is exacerbated by a lack of proper knowledge about basic preservation techniques at the household level⁹. 

Even before the rise of Boko Haram, the northern regions were a victim to the effects of climate change and desertification which resulted in sporadic droughts and food shortages. Now, violent acts of Boko Haram such as seizure of livestock and food supplies, impoundment of farms and closure of markets, have resulted in the a warning from the Early Famine Warning system in Nigeria from USAID⁹.

Key Indicator of Malnutrition: Stunting  

Stunting is a global indicator of malnutrition defined by the World Health Organization as the “impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation”⁴. Stunting is measured by the child’s weight and height which is then compared to an accepted set of values. Those who fall below their accepted age groups values are said to be stunted. Stunting can be especially harmful to the developmental function of the child, often harming cognitive and education performance and has long term risks such as low adult wages and lost economic productivity. In fact, stunted children have on average 13 fewer IQ points, are more likely to start school later, perform more poorly on cognitive functioning tests, and are more likely to dropout of school⁴. Adults who were stunted as children earn 20% less than non-stunted adults and are 33% more likely to live in poverty⁴. Reports from UNICEF also concludes that malnutrition can reduce GDP in some countries in Asia and Africa by as much as 2% to 11% each year⁴.

While stunting is a key factor in delineating those who are at risk for malnutrition, it’s important to recognize that stunting disproportionately affects those in low income and rural households. The stunting prevalence for children in Nigeria under five in a rural group is 43% while those living in urban areas is 26%⁸. Those living in a rural area are less likely to have access to fresh markets, be near trading ports and have access to transportation. Moreover, children under five in a lower income bracket are 50% more likely to be stunted, than those from a higher income household⁸. The poorest children are also 3.2 times likely to be wasted, as defined by having low weight for height. Even obesity, an emerging public health problem affects children in poorer household at a higher rate ( 4.9%, as compared to 3.2%) than children from the richest households⁹. This may be due to the uptake of insufficient nutrients or not being able to afford healthy alternatives⁸. 

It’s also important to note the existence of  “intra-urban” inequalities in Nigeria.  Urbanization has increased the urban population from 29.7 percent in 1990 to 47.8 percent in 2015⁸. By 2050, over 67.1 percent of Nigerians are estimated to live in urban areas⁸. Rapid urbanization brings increased slum areas and slum populations that might not have proper access to water and sanitation programs, making them highly vulnerable to developing infectious diseases. These inequities in urbanization are further exacerbated in the context of conflict where many households and families become a double victim to their situations. For example, Boko Haram’s violent acts occur in the northern rural regions of Nigeria where 72 percent of the population lives in poverty. The northern region is already less likely to have access to health care, hospitals, clinics and pharmacies, making the region extremely susceptible to the challenges brought by conflict⁹.  

Undernutrition in Children in Nigeria 

It is estimated that over 30 percent of children in Nigeria under 5 and over 20 percent of pregnant women are Vitamin A deficient¹¹. Moreover, 76 percent of preschool-aged children and 67 percent of pregnant women are anemic¹¹. Reason for this include inadequate dietary intake of iron, and exposure to infections and parasites. Furthermore, one in five households do not consume adequate iodized salt, thereby predisposing these children to IQ losses of up to 13 points, increasing the risk of stillbirths, and wasted pregnancies¹¹. The World Bank predicts that Nigeria loses over US$1.5 billion in GDP annually to vitamin and mineral deficiencies alone. Therefore, it is important to address the nutrition not simply as a health issue but also as a development and economic issue¹¹.

Gender Inequality and the role of women  

A child’s chances of facing malnutrition and being stunted can depend on the mother’s health. Women who are stunned are more likely to give birth to children who are stunted and underweight. The age at which women gives birth is also linked to her socio-economic and location status^4,8. In Northern Nigeria, adolescent girls (aged 15-19) give birth at a younger age than those living in the southern regions⁴. Furthermore, 1 in six teenagers in Nigeria is a mother and 34% of adolescents mothers are from poor households⁴. Since adolescent mothers have not finished growing up yet, the baby and the mother might compete for nutrients, therefore increasing the chance that the baby will be underweight and more likely to be stunted ¹¹. 

 It’s important to note that these differences between the north and the south are a result of cultural and religious differences. Generally, women are less likely to be educated than men, and have less control over resources and decision making in the household, which leaves women with lower access to food, water and other necessary resources. Similarly, due to natural sex differences, socio cultural traditions and household patterns, women are more likely to suffer from nutritional deficiencies. A women’s disempowerment cause set the scene for maternal undernutrition and can weaken a woman’s ability to survive childbirth, increase vulnerability towards infections, increase her chances of having low-weight children^9,11. 

Existing Government Response: The Food and Nutrition policy of Nigeria 

To combat malnutrition in children under five, Nigeria has laid out a multi-sectoral framework that aims to “attain nutritional status for all Nigerians by the year 2025”⁸. The framework lays out several targets such as to “improve food security at the national, community and household levels involving various sectors such as health, agriculture, science and technology, education and economy⁸. The National Food and Nutrition Policy also aims to delineate undernutrition among infants and children and increase the knowledge of nutrition among the population⁸.  

One of the targets laid out by the Food and Nutrition policy of Nigeria is to increase exclusive breastfeeding rate from a rate of 17% in 2013 to 65% by 2025. It aims to do so by supporting early initiation of breastfeeding within thirty minutes of delivery, and by promoting exclusive breastfeeding through the first six to twenty four months of life. Exclusive breastfeeding which prohibits other liquids, such as water and solids from being administered to children allows children to achieve optimal growth and development (WHO). In Nigeria, the National Demographic and Health survey found that only 10 percent of children 6-23 months were fed in accordance with infant and young child feeding recommendations. This gap in understanding shows us that treating malnutrition requires an educational approach, one where teaching mothers and communities about proper nutrients uptake can be a cost effective way to reduce malnutrition in children, and therefore reduce childhood mortality. 

Nutrition in Conflict areas: Short term Interventions 

For children suffering from malnutrition, especially in conflict areas, access to immediate relief is an one of the most important priorities. One such intervention that has been implemented is a Community-based Management of Acute Malnutrition in Nigeria which has treated over 2 million children at a cost of US$160 per child¹². For eight weeks, the mother brings her children to a healthcare facility once a week to seek information about malnutrition as well as receive Ready-To-use-Therapeutic Food, a peanut-based paste that contains milk powder, sugar and multiple micronutrients¹². However, this intervention can be difficult to address in areas such as Northern Nigeria, where access to health clinics has been destroyed. While rebuilding health clinics rebuilding is a long term goal, distribution of Ready-To-use-Therapeutic Food is viable short term intervention, which can be implemented via local community actors such as churches, mosques and schools. A holistic partnership can be taken by including the Lagos-based Nigerian company, DABS, which received an international certification to produce RUTF for the treatment of malnutrition. Working with local business to create RUTF will no longer make the government dependent on imports, which means that the intervention will be cheaper and more effective to transport and distribute¹¹.

 Participation from the local community to address and raise awareness about vitamin supplements and deworming tablets in schools can prove to be an effective way to relay information as it relies on existing infrastructure to address the problems. 

Long term solutions:Adopting a multi-sectoral approach

Approaching malnutrition as a multi-sectoral solution will not only relieve short term concerns but lay the foundation for long-term benefits. Evaluating the social determinants of health to address the access to food, hygiene, housing are key to addressing malnutrition in Northern Nigeria. On a larger scale, addressing poverty and women’s status in society is also important to improving the decision making around malnutrition. 

From an agricultural perceptive, Nigeria biofortified cassava, one of the staple foods along with rice, maize and wheat to address vitamin A deficiency. A World Bank study has shown that the introduction of three new cassava varieties to over 50,000 farmers has a likelihood of covering 25% daily need of Vitamin A and reach over 2 million people. Fortifying food can be possible with a collaboration from the private sectors such as HarvestPlus and local farmers. Another way to promote multi-sectoral collaboration is to promote the research of agricultural techniques by increasing funding to local and national universities. 

Addressing the inequalities and inequities caused by poverty is key to decreasing the malnutrition rate in Nigeria. Access to education, especially in the northern region is an important investment in providing educational opportunities for the future of Nigeria¹¹.

Long term solutions:Addressing Boko Haram

Implementing interventions in significantly more challenging in Northern Nigeria due to the lack of infrastructure, lack of healthcare workers and  a displaced population who are in need of basic supplies. In order to implement short and long terms interventions in an aim to fight malnutrition in northern Nigeria, Boko Haram must be challenged and addressed by not just the government of Nigeria but by the international community as well. The Nigerian government with collaboration from the United Nations, European Union and the United States should investigate and hold the leaders of Boko Haram accountable. The international community can also publicly denounce the attacks on schools and other infrastructure by the military and the Nigerian Government. 

Partners in funding and accountability: Local and international actors 

Outside charities such as the Children’s Investment Fund Foundation (CIFF) have also provided US$60 million and challenged the leaders in northern Nigeria to raise funds in the hopes of matching donations. Other multi-sectoral partners can possibly include international aid groups such as UNICEF, DFID, Helen Keller International (HKI), Micronutrient Initiative, Save the Children UK, Global Alliance for Improved Nutrition (GAIN), Action Against Hunger, Valid International and Food Basket International. Collaboration between the international organization, the Nigerian government and local communities is vital to implementing interventions and monitoring growth and progress. This can be done by implementing a multi-step budget approval from key stakeholders, including private and community and local actors.  To keep track of progress, data for maternal mortality, child mortality, average income, growth of the population should be transparent to all stakeholders. 

Conclusion: Why addressing malnutrition is key to Nigeria’s future.  

 By 2050, Nigeria’s population will reach over 398 million, and becomes the third largest country in the world. Over 40% of this population will be under 20, which represents an incredible opportunity for Nigeria to address and ensure that its future leaders can reach their full potential (10). Funding in nutrition is not only just a imperative health issue but also an economic one. The Ministry of health notes that investing in nutrition provides high yield returns for the economy. Every dollar invested in interventions targeting stunting would yield an estimate of 10 dollars¹¹. Similarly, every dollar invested in anemia prevention can yield up to 5 dollars¹¹. When issues such as malnutrition will be addressed, the potential of Nigeria’s next generation will be unleashed. 

To recognize the underlying causes of malnutrition is to understand the intersectionality that addresses malnutrition as a food, environmental, economic, hygiene, and women’s and children’s issue. If Nigeria aims to reduce malnutrition, it must implement a multi-sectoral approach that addresses underlying factors such as poverty, lack of education, lack of economic opportunity and female empowerment. Furthermore, taking a human rights approach and aiming to build structures that are more equitable to marginalized populations will ensure that all individuals are given the opportunity to live a healthy life. Addressing malnutrition in northern Nigeria will take a step towards fighting for a peaceful, stable and health future, that all generations of Nigerians deserve. 

Aastha Kc is a sophomore in Pauli Murray College. Aastha is an Anthropology major from Georgia. She can be contacted at aastha.kc@yale.edu. 

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References: 

1. International Rescue Committee (IRC). Juliette Delay Global Communications Officer, International Rescue Committee
2. “SDG:2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture .:. Sustainable Development Knowledge Platform.” United Nations, United Nations, sustainabledevelopment.un.org/?page=view&nr=164&type=230.
3. World Health Organization, “The WHO Child Growth Standards” (2014), accessed at http://www.who.int/childgrowth/en/, April 2014
4. Federal Government of Nigeria. Malnutrition: Nigeria’s Silent Killer. pdf 
5. Vanguard. “Declare State of Emergency on Malnutrition, Reps Tell Ministry of Health.”Vanguard News, 11 Oct. 2017, 
6. “Nigeria.” Demographic Dividend, www.demographicdividend.org/country_highlights/nigeria/.
7. Save the Children. “Scaling up nutrition interventions for children left behind in Nigeria.” Save the Children. 2016. N.page. Web. 12 December 2017
8. United States, Congress, “The Struggle against Boko Haram .” The Struggle against Boko Haram , ser. 113-220, U.S Government, 2014. 113-220. 
9. Ransom, E.I., Elder, L.K., “Nutrition of Women and Adolescent Girls: Why It Matters.” Nutrition of Women and Adolescent Girls: Why It Matters, www.prb.org/Publications/Articles/2003/NutritionofWomenandAdolescentGirlsWhyItMatters.aspx.
10. “Nigeria.”“Population Pyramids of the World from 1950 to 2100.” Population Pyramid.net, http://www.populationpyramid.net/nigeria/2017/.
11. Akuoko, J.K., Dayton, Julia., MacDonald, C., Shekar. (2014). World Bank. “Costed Plan for Scaling up Nutrition: Nigeria.” World Bank Group. Health, Nutrition and population.