Two years old is what one would assume, at the first glance. However, the size of his feet, hands and head give him away.
Alfajiri Muzamiru is four years. But he could pass for a two-year-old. He is way too short and small for his age, hence stunted.
His aunt, Aisha Mariam, 24, looks at him with pity as she explains his condition, "I do not understand why he is not eating, even now that we are in hospital and he is receiving treatment. He keeps vomiting everything he eats."
Muzamiru is a patient at the Mwana Mugimu children's ward, at Mulago Hospital.
He is among the 26 million stunted children in eastern and southern Africa. About 10 million of those are in East Africa, according to Noel Marie Zagre, the regional nutritional advisor, UNICEF East and Southern Africa.
Owing to its prevalence, stunting was a focus of discussion at last year's commemoration of the Africa Day for Food (ADFNS) and Nutrition Security, held in Addis Ababa, Ethiopia.
The day was endorsed by the African heads of state and governments during the 15th African Union Summit in Kampala, in July 2010, to be commemorated annually by all member states on October 31.
The ADFNS 2012 aimed at providing a platform to engage food and nutrition security stakeholders, governments, civil society and the private sector towards fighting acute malnutrition and stunting.
"Stunting is the irreversible outcome of chronic nutritional deficiency during the first 1,000 days of a child's life. The damage it causes to a child's development is permanent," said Akila Aggoune, the head of UNICEF liaison office and representative to the African Union at the celebration.
Stunting and other forms of malnutrition, including micro nutrient deficiencies, during the first two years of birth cause irreparable harm to children's opportunities in life.
"They impede physical growth and lead to irreversible mental damage, hampering their learning abilities.
Stunted girls are more likely to have small and low birth weight babies," said Elhadj As Sy, UNICEF's Regional Director for Eastern and Southern Africa.
Zagre said stunting in third world countries is responsible for 0.7% of lower grades in schools. He explained that it is so because stunting is responsible for reduced mental capacity, seven month delay in starting school, all translating into 22 to 45% potential reduction in lifetime earnings and 2-3% losses in the country's Gross Domestic Product.
The relationship between GDP and stunting is also acknowledged in the Uganda Nutritional Action Plan, a country-led initiative to strengthen national nutrition, that there will be a strong return on public investment. "For every sh1,000 invested, about shs 6,000 worth of increased productivity will result from reduced child stunting."
Similarly, Aggoune explains that a stunted child will never learn, nor earn, as much as he or she could have if properly nourished early in life.
Zagre warned that stunting is silent. "Just because the child is playing does not mean they are okay. Stunting is not visible, but with huge consequences."
He advised that the condition is best addressed when the 'window of opportunity' is utilised to shape a healthier future.
"This window is from pregnancy to two years, or else s/he will be stunted for life," he explained.
"The right nutrition during this 1,000-day window can have a profound impact on a child's ability to grow, learn and rise out of poverty. It can also shape a society's long-term health, stability and prosperity," said Zagre.
However, while a number of African countries are embracing the fight against malnutrition, Bibi Giyose, senior advisor - Food and Nutrition Security - to the African Union's New Partnership for Africa's Development, said they may not realise results because of not opting for an approach that cuts across all government departments.
Gary Quince, the European Union Special Representative for the African Union, noted: "Many countries in Africa place issues to do with nutrition under the health departments. We should help them develop a more holistic approach to nutrition."
Professor John Otim, a senior presidential advisor in Uganda, said: "In malawi, the gospel is preached to leaders who pass on the message to those at the grass roots. This has drastically reduced cases of malnutrition. If we adopt that strategy, using the traditional leaders and Members of Parliament, we should be able to achieve."
Stunting in Uganda
The Uganda Health Demographic Survey (UDHS) indicates that the prevalence of stunting is at 33%, with western Uganda and Wakiso district being the worst hit.
Dr. Elizabeth Kiboneka, the head of Mwana Mugimu nutrition department at Mulago Hospital, says: "In Wakiso, neglect is the cause of the poor nutrition. Children are left home alone or with housemaids, who may not care about feeding them."
Professor Otim blames malnutrition on poverty. He notes that in urban areas, the poor do not have purchasing power to buy the necessary food to diversify the diets.
A survey conducted by Uganda Bureau of Statistics (UBOS) in 14 southwestern districts in 2011, showed that nearly half of the children below the age of five were stunted.
The bureau's former head, Male Mukasa, said 14% of the children were severely stunted.
"Stunting among children below five years has decreased from 49% in 2006 to 42% in 2011 in the region. Although there is a decline in the proportion of stunted children in southwestern region, the figure is still higher than the national level average of 33%," Mukasa said.
Among the reasons for stunted children is that peasants are selling off land to commercial farmers and migrating to towns where they struggle to feed their children.
Dr. Robert Mwadime of USAID-Uganda. blames the stunting on women's workload. They barely have time to attend to the nutritional needs of their children. He also notes the poor eating patterns of solely starch, like cassava and potatoes.
"A visit to south western Uganda reveals numerous food gardens, but what we see is not owned by all the residents there," he notes.
Professor Otim notes that ignorance is one of the driving factors of malnutrition in Uganda.
"People are not aware of the need to prepare food that is balanced and nutritious. Therefore, if the Government is to succeed in plummeting the malnutrition levels, educating mothers and fathers about the importance of nutrition and access to a balanced diet is vital," Otim advises.
Strategy in Uganda
The Uganda Nutrition Action Plan, launched in October 2011 is an example of a recent country-led initiative to strengthen national nutrition.
The plan, prepared by the Uganda National Planning Authority, sets out guidelines for districts to implement nutrition programmes, aimed at improving maternal and child health by reducing malnutrition in women of reproductive age, as well as infants below two years.
According to the plan, the Government has adopted the Scaling Up Nutrition strategy of focused interventions covering the 1,000-day window of opportunity directed at women in the reproductive age, newborn babies and children under two years.
Kiboneka notes that with policies like the first 1000 days, Uganda is making progress towards kicking out malnutrition and its effects.
She adds that the 1000-day emphasis translates into a healthy intelligent child. The 1000 days are broken down into; the 60 days before conception, where women should eat a balanced diet, followed by the period of pregnancy, where she should have enough iron and folic acid for the baby's proper development.
As soon as baby is born, breastfeeding is initiated within the first hour, and after, it is done at least eight times a day and on demand until six months. A balanced diet must be ensured until the baby is two years.
Mwadime says initially, nutrition was under the health and agriculture ministries, but fighting malnutrition would need working closely with other sectors. In the education ministry, for example, teachers can teach the children and children reach their parents and colleagues, or ministry of trade, where when an adult buys oil and wheat, they are advised not to forget to give the baby some of it.
Challenges facing remedial strategies
Dr. Robert Mwadime of USAID-Uganda notes that much as the Government is fighting malnutrition, it has focused on western and northern Uganda.
"What about the east? It's a time bomb. Those designing the strategy should make sure efforts to fight malnutrition are spread out to different areas," says Mwadime.
He adds that if concentration is targeted towards particular areas, the condition may worsen elsewhere, like it happened in Namutumba, where malnutrition claimed lives of babies.
Mwadime also blames the current surveillance system. "It is not strong enough to tell us where problems are likely to get out of hand, such that we avoid 'putting out fires' but prevent them altogether.
In the past, we have been a country of 'putting out fires,' but if malnutrition is to be fought, the surveillance system should be strengthened."
He notes that ensuring grassroots communities are reached by the various programmes fighting malnutrition was crucial.
He says that for example through groups like National Agricultural Advisory Services in the different districts, information is passed on.
However, the actual people who are in need are barely reached. Mwadime says the poor, chronically ill, orphaned, alcoholics in the community, who are the most malnourished, rarely attend the groups, yet they need this information more.
He explains that since the poor spend most of their time in casual labour, the strategies to fight malnutrition should improvise on reaching them in the market places, where they sell their produce, at religious places and rough radios.
"Also, working more with those who deal directly with them such as the village health teams and community health workers is vital."
That, however, is not the case, currently, as most times, the people in need are not reached.
What Govt can do
Ensuring a coherent policy and legal framework. At a conference on stunting in Ethiopia last year, it was noted that some countries do not have polices for food security and nutrition.
Governments should embark on financial tracking and resource mobilisation for food security and nutrition.
42% Stunting among children below five years has decreased from 49% in 2006 to 42% in 2011in southwestern Uganda
26 million-The number of stunted children in eastern and southern Africa
2-3% - Losses in the country's Gross Domestic Product due to stunted growth