Malnourished Children, Dull Adults

Poor Brains, Little Adults -  How Malnutrition Threatens Nigeria’s Future
Credit: ITN Productions/British Council

With one-third of children under the age of five stunted due to nutritional deficiencies, Nigeria faces an explosion of children with poor schooling outcomes.   

By Chikezie Omeje

Hudu Adamu is a seven-year-old Class 2 pupil of J/Tsada Special Primary School in Dutse Local Government Area of Jigawa State. Sitting among his peers under a Dogoyaro tree outside the school, he is faced with a sudden challenge. He has just been asked to recite English alphabet by a senior pupil.

He steps out of his seat on the tree’s ruptured roots, smiling shyly and hesitantly, and hiding his face from the observers. Two secondary school leavers who speak passable English among the group nudge Adamu to respond to the challenge.

“A, B, C, D E, F,” Adamu begins uneasily but stops abruptly. All eyes are on him but the noise of the passing motorcycle deflects the tension and affords him a moment to comport himself.

With a worried smile, he starts all over again and mumbles incoherently after the letter “F”.  On his third attempts, he succeeds in adding letter “G” but mumbles thereafter.

Disappointed by Adamu’s failure, one of the secondary school leavers points to another child, Narisu Nuhu to recite the English alphabet. Unfortunately, Nuhu is as bad as Adamu.  They both continue to try but make no progress beyond letter “G”.

Nuhu is in Primary 3 in the same school and is a year older than Adamu.

There are three other children among the group playing nearby along a dusty road to Dutse town. These ones are not in school despite having a school just a stone throw away from their homes.

By Nigerian educational standard, both Adamu and Nuhu are expected to be able to read simple words in English as pupils in primary school are taught in English, Nigeria’s lingua franca. Their inability to recite the alphabet which is the basis for learning how to read in English may be a sign of cognitive deficiency.

Adamu and Nuhu appear to be too short for their age, an indication that they are stunted. Stunting is an indication of chronic under-nutrition, which is caused by a prolonged period of hunger or disease. Stunting which reflects a failure to grow in stature also causes mental growth retardation.

Scientific evidence shows that stunted children are more likely to have cognitive deficiencies and poor learning outcomes. A report by the Save the Children shows that malnourished children score 7% lower in mathematics tests, are 19% less likely to be able to read at age 8 and are 13% less likely to be in the appropriate grade for their age than those who are well nourished.

The first 1,000 days of a child’s life, from conception to two years of age, are very critical. It is considered that a baby who lacks essential nourishment during this period that the brain is developing rapidly may have mental retardation that is irreversible.

Scientists believe that stunted children grow into adults with irreversible losses in human capital that also contribute to future losses in economic productivity.

Adamu and Nuhu are growing up in a state which has the highest rate of stunting among children less than five years of age and there is a probability that malnutrition is the main cause why children in the state are less likely to go to school or perform well in school.

National Nutrition and Health Survey, NNHS 2015, shows that 63 per cent of under-five children is stunted in Jigawa State. This alarming figure of stunting is also reflecting in the schooling outcomes in the state.

If Adamu and Nuhu are growing up in the southern part of the country where stunting rate is less than 25 per cent among under-five children, they are more likely to do well in school as clearly shown in the 2015 Nigeria Education Data Survey, NEDS.

Schooling outcomes are very abysmal in states where malnutrition is high. In Jigawa State, 83 per cent of school-age children from 5 to 16 years cannot read. This high level of illiteracy is also common to all the states in the North West and North East where child malnutrition is almost twice the national average.

Apart from literacy, comprehension and numeracy are extremely low in the states with a high number of stunted children.  In Jigawa State, only 9 per cent of school-age children can understand what they are taught and 85 per cent of them are unable to solve basic numeracy.

Schooling outcomes are much better in the southern part of the country. In Anambra State, which has the least rate of stunting at 7 per cent, illiteracy among school-age children is 28 per cent.  Comprehension is also high at 47 per cent and it is only 22 per cent of school-age children that are unable to solve basic numeracy in Anambra State.

Both Adamu and Nuhu are in the appropriate grade for their age but they are not showing evidence of learning. Official school age in Nigeria is six years and Adamu who is in Grade 2 is seven-year-old while Nuhu who is eight-year-old is in Grade 3.

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“What usually is the problem is that people who are malnourished remain like that. They have permanent brain retardation. They have what we call cognitive deficiencies. They are not able to catch up as adults,” Kabiru Ibrahim, the Executive Secretary of Jigawa State Primary Health Care Development Agency told icirnigeria.org.

Malnutrition in Jigawa
School age children pose for a shot at Dutse, Jigawa State

The 2016 school enrolment data by the Jigawa State Ministry of Education shows nearly one million students in both primary and secondary schools in the state but performance in external examinations is abysmal compared to states with low stunting rate.

“When we are presenting people who have five credits in WAEC, here we are presenting 11 per cent. Abia presented 81 per cent,” says Ibrahim.

Surprisingly, the state’s ministry of education in its 2016 report listed poor quality of teachers, overcrowded classrooms and poor infrastructure as the main factors for the pupils’ poor school performance without mentioning malnutrition.

Malnutrition and schooling outcomes

Malnutrition is mainly caused by insufficient nutrient intake and a study shows that food insecurity is linked to specific developmental consequences for children.

“If you don’t eat well, what can you do well? It affects all lifestyles,” says Ado Ibrahim, the Head of Primary Health Centre, Sokwaya Ward in Dutse Local government Area of Jigawa State, adding that malnutrition is a major challenge in the state.

It is not just a coincidence that Jigawa State which has the highest rate of stunting also has the highest rate of illiterate school age children or the regions which have a high level of malnutrition also have worst schooling performance.

With 63 per cent rate of stunting, NEDS indicates that literacy and comprehension among school-age children in the state is just 9 per cent while numeracy is 7 per cent. Net attendance ratio among primary school pupils is 53 per cent while gross attendance ratio is 71 per cent.

But malnutrition affects all the states in the federation. One-third of Nigerian children who are under the age of five years are stunted. Stunting rate in the country is 32 per cent but there is a huge regional difference.

Jigawa malnutrition infographics

The seven states in the North West have the highest cases of malnutrition with 55 per cent of children being stunted.

Despite the Boko Haram crisis in the North East, the region is still ahead of North West as 43 per cent of children are stunted.

Just as malnutrition is higher in North West and North East, the two zones also have the highest level of illiteracy among school-age children in the country. In both regions, 72 per cent of school-age children from 5 to 16 years are illiterates.

The North Central, where nutrition is better than the other two northern regions, also has better outcomes in school performance and learning. Stunting is 30 per cent in the region and this also reflects in literacy as 44 per cent of school-age children are literates, compared 29 per cent in other two northern regions.

The southern part of the country where stunting is less than 25 per cent shows a remarkable level of literacy among school-age children but there is a curious variation.

While the South East has the least rate of malnutrition, it does not have the highest percentage of literate children. However, the region leads in external examinations like West African Examination Council, WAEC. Stunting among children in the South East is 12 per cent while illiteracy among school age children is 39 per cent, although illiteracy in Anambra State is 28 per cent among school-age children.

The South West, which follows the South East in the least rate of stunting at 17 per cent, has the lowest level of illiteracy at 26 per cent. In the same vein, the South South has 20 per cent rate of stunting and second least rate of illiteracy at 28 per cent.  Perhaps, Lagos and Rivers states account for this significant decline in illiteracy in both regions as they have 11 and 14 per cents respectively, far above the averages in the regions.

Moreover, the pattern of malnutrition clearly reflects in the primary school attendance ratio. The South East having the least stunted children has the highest school attendance ratio of 85 per cent, followed by South West and South South at 83 per cent.  However the North West and North East with the highest level of malnutrition among children have the least ratio of primary school attendance at 47 and 45 per cents respectively. The North Central has 76 per cent primary school attendance ratio.

Anambra State is completely opposite of Jigawa. By having the lowest rate of stunting at 7 per cent, Anambra has one of the best schooling outcomes in literacy, comprehension, and numeracy among school-age children as well as leads in external examinations in the country.  Literacy in the state is 71 per cent while comprehension and numeracy are 47 and 77 per cents respectively.

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This, however, does not mean that there are no malnourished children in the state.

“We also have cases of malnourished children. We have the data,” says Chioma Ezenyimulu, the Executive Secretary of Anambra State Primary Healthcare Development Agency.

Ezenyimulu, however, insists she will not speak further on malnutrition in the state until our reporter produced an official letter requesting information.

A teacher at a public primary school in Awada, Onitsha, Chineye Oranekwu, believes that what makes a difference in a pupil’s learning achievement is the quality and commitment of teachers.

While Anambra may have more qualified teachers than Jigawa State, malnutrition may actually make much difference.

A study shows that malnutrition disorders affect more than 42 per cent of school children in Nigeria and are responsible for 49 per cent absenteeism of primary school age children.

“We are overwhelmed with malnutrition”

As the federal government and international community are focusing and mobilising resources to the humanitarian crisis in the North East, children who are threatened by malnutrition in states considered very peaceful have largely been ignored.

Last year, the federal government budgeted N2 .4 million for nutrition but unfortunately, this paltry sum was not released.

For the first time, the federal government is budgeting N1.2 billion this year for contribution and counterpart funding for a UNICEF nutrition project to provide Ready to Use Therapeutic Food, RUTF, for severely malnourished children. But this sum is insufficient considering the number of children who are severely malnourished and are in need of treatment with RUTF.

Last December, the Chairman, Senate Committee on Health, Olanrewaju Tejuoso, demanded N95 billion to be budgeted this year to procure RUTF to treat children under the age of five years who are severely malnourished in the country.

Tejuoso told icirnigeria.org that the N95 billion will be used to treat 1.9 children at an estimated cost of N50, 000 per child.

Overall, 2.5 million under-five children are severely malnourished across the country but UNICEF pledges to support the treatment of 600,000 children in 2017 with RUTF while the Nigerian government is expected to cater for the remaining 1.9 million children.

Mothers feeding their babies with RUTF in CMAM centre, Sharada, Kano State
Mothers feeding their babies with RUTF at CMAM centre, Sharada, Kano State

For the past seven years, UNICEF has been implementing Community-based Management of Acute Malnutrition, CMAM in the North West and North East that have the worst concentration of malnourished children.

UNICEF says more than a million children have been successfully treated for malnutrition and more than 200,000 deaths averted through the CMAM programme.

However, a greater proportion of children who need the treatment is not being reached due to limited funding. According to UNICEF, two out of every three children still do not receive the treatment they need in the eleven states where CMAM operates.

UNICEF Country Representative, Jean Gough calls for a scale up of CMAM.

“It is a proven high-impact intervention that is saving lives and helping Nigerian children reach their full potential through a good start in life,” says Gough. “We need greater investment in Nigeria’s future by investing in good nutrition”.

Jigawa State has 67 CMAM centres in 12 out of the 27 local government areas in the state, indicating an overarching need to expand the programme in the state to reach more children.

“We are overwhelmed with malnutrition,” says the Executive Secretary of Jigawa State Primary Health Care Development Agency, Kabiru Ibrahim.

Ibrahim says the state is supporting CMAM through procurement of drugs to treat the malnourished children of diseases and infections.

He says, “Every malnourished child has a package of diseases and infections which must be addressed before giving RUTF. If you don’t do that, it is like pouring water into a basket. So the provision of those drugs is a lot of money. Each child will consume N800 worth of drugs each time the child visits the clinic and we are talking of about 60,000 children in a year”.

This year, the state has budgeted N300 million for nutrition with the aim of expanding CMAM to more communities in the state. But the sheer number of children who need to be treated pales the effort of the policy makers in the state.

“We are overwhelmed. We have written letters to development partners to help the state. It is a complex issue,” Ibrahim says.

On September 8, 2015, Nigeria launched the National Strategic Plan of Action on Nutrition, (NSPAN 2014 – 201). The policy is expected to reduce stunting by 20 per cent in 2019 but the plan has not been funded by the government.

This reality saddens Philippa Momah, the Coordinator of Civil Society for Scaling-up Nutrition in Nigeria, CS-SUNN.

“How can a policy be developed for 2014 to 2019, and yet there is no funding for it,” says Momah.

Momah wonders why nutrition is not seen as a priority in a country where over 11 million under-five children are stunted.

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The country’s failure to fund nutrition betrays its global commitments. Nigeria signed up to the Scaling-up Nutrition, SUN movement in 2011 and also signed the global Nutrition for Growth Compact in 2013. In doing so, Nigeria committed to the global movements for tackling its high rate of child malnutrition.

Intervention: Too little or too late

The official school age in Nigeria is six years and the federal government’s school feeding programme which has taken off in some states provides one meal each day in school for pupils in grade one to three.

The school feeding programme is anchored on the concept that it will improve the nutritional status of the pupils, increase school enrolment, enable them to stay in school, improve learning outcomes and reduce the financial burden for parents.

But by the time the children reach the age of schooling to start receiving the meal at school, mental retardation as a result of early onset of malnutrition might have occurred and it is essentially irreversible.

Malnutrition is the main cause of deaths among under-five children in Nigeria. The Federal Ministry of Health, UNICEF and WHO say malnutrition accounts for a half of under-five mortality in Nigeria. It is estimated that each day, 2300 under-five children die in the country.

But the biggest threat of malnutrition is not just death but those who survive malnutrition face a life-long learning disability.

According to World Bank, childhood stunting is estimated to reduce at least 10 per cent of potential lifetime earnings.

World Bank Group on Health, Nutrition and Population in its “Costed  Plan for Scaling Up Nutrition in Nigeria” notes that “For those malnourished children who survive, there are long-lasting health and schooling consequences, including cognitive deficits and poorer schooling outcomes. Children with impaired cognitive skills have lower school enrolment, attendance and graduation, which in turn results in lower productivity, earnings and economic well-being. Stunted children lose 0.7grades of schooling, and are more likely to drop out of school.”

The school feeding programme is a laudable social investment but may be too late for those already malnourished. And it is also too expensive.

If federal government implements the programme in all the states of the federation, it will cost not less than N100 billion annually.  The money if invested in early nutritional interventions during a child’s 1000 days will have more impact on schooling and save more lives.

Photo credit: osun.gov.ng
Photo credit: osun.gov.ng

But then, school-based feeding programme is a good social investment too, as shown in the case of Osun State, where the programme has been successfully implemented since 2006.

The State spends about N3.2billion annually to feed 254,000 pupils from Grade 1 to Grade 4, with the aim of reversing the very low academic performance of pupils through good nutrition for cognitive skills development. The programme has increased school enrolment in the state by 25 per cent.

According to the state’s record, the programme brought an increase in enrolment within a few weeks of its introduction from 155,318 to 194,320 pupils.

Teachers at Union Baptist Government Elementary School, Osogbo say the school feeding programme provides an incentive for the pupils to stay in class and learn without being distracted by hunger.

Our reporter who visited the school on a Monday observed how accredited food vendors gave each pupil boiled egg and palm-sized bread during break time.

Oketayo Adeolu, the Programme Manager of Osun Elementary School Feeding and Health Programme, O-MEAL says the feeding intervention has led to overall improvement in academic performance compared to when the programme was not in place.

Adeolu said some of the children take their first meal of the day in school through the programme. “There are cases where children have not eaten egg before but through this programme, they are now eating. We may not believe it but these conditions are real. If someone who has not been eating food in the morning, now come to school and eat food from Monday to Friday, at least it will offset any form of malnutrition. It has helped. There have been minimal cases of illness among school children,” he stated.

Akinjogbin Olabode, Operation Officer, O-MEAL says the programme has improved school attendance, retention and completion by pupils.

Olabode believes that the actual impact of the programme on school performance will be determined through a study which has not yet been done.

But if the programme has led to improved academic performance of the pupils, it appeared to be minimal. Performance among school-age children in the state is not significantly better than children in the neighbouring states of Ekiti, Ogun and Lagos, except in Ondo and Oyo states.

Literacy among school-age children in Osun as indicated by NEDS 2015 is 73 per cent, likewise Ekiti and Ogun states while Lagos is 89 per cent. It is 60 per cent in Ondo and Oyo states.

But whether too late or too little, government’s intervention in nutrition for school age children is critical for the future of the country.