On the last day of October 2022, four women from conflict-affected communities in Niger State arrived at Kontagora General Hospital. They were all carrying children who appeared to be severely malnourished. Kontagora General Hospital is in Kontagora town in north-west Niger State. The town is surrounded by smaller communities like Bangi, Shadadi, Kamfani Bobi, and Kuchi most of which have been severely affected by the banditry in the state.
While the nurses attended to the children, Dr. Ocholi Okutepa who oversees the 'Out and In-patient Treatment of Malnourished Children' Unit questioned the mothers: "What kind of meals do you eat? Do you make enough milk for breastfeeding? When did you first notice that your child was losing weight?"
Working with the answers the mothers provided and after screening them for malnutrition using Mid Upper Arm Circumference (MUAC), weight, and height measurements, the children were diagnosed with Severe Acute Malnutrition (SAM) and admitted into the hospital because they were in danger of developing hypoglycemia, a condition where blood sugar levels fall lower than the standard range. SAM is one of the most dangerous forms of acute malnutrition; if left untreated it can result in death.
In Nigeria, 45% of the over one million under-5 deaths that occur every year are attributed to malnutrition. Between 47 and 50 percent of the children in the northeast and the northwest suffer from malnutrition. The statistics are lower in the north central and southern part of the country, at 29% and below 20%, respectively. The United Nations Children's Fund (UNICEF) reported that an estimated 11 million children in Nigeria are stunted while an estimated 2.1 million children under 5 suffer from wasting.
No life-saving essentials
Since 2019, as a result of the insecurity in Niger State, more than 150,000 people have fled their homes and farmlands. Dr Okutepa revealed that this has put a lot more children at risk of severe malnutrition. In February 2022, after one of such attacks, a good number of the people -- most of whom were women and children -- made their way to Kontagora., a suburban town in the northwest region of Niger State.
According to Dr Okutepa, at this time, the hospital was receiving up to four malnourished children daily, which was a seven-fold increase from the weekly average of four children 9 months earlier. While the hospital admits all severely malnourished children and gives them beds, there are no Ready-to-Use Therapeutic Foods (RUTFs) that can be given to the children suffering from severe acute malnutrition.
Ready-to-Use Therapeutic Foods are nutrient-rich biscuits and pastes made from powdered milk, peanut butter, vegetable oil, sugar, and a mix of vitamins and minerals. They are life-saving essentials used to treat severe and acute malnutrition in children under five years old. However, it is not readily available in the country.
The Niger State Nutrition Officer, Asmau Mohammed said that the state relies on UNICEF for its matching contribution to the provision of RUTFs and other nutrition-related commodities for malnourished children. However, owing to the state's failure to fulfill its counterpart financial obligation to the programme, government-run healthcare facilities like Kontagora General Hospital have been without these essential supplies for more than 2 years.
'I thought my baby was going to die'
In a bid to provide a lifesaving cost-effective alternative for the malnourished children in their care, Okutepa and his team started offering them fortified blended meals made with crayfish, soybean, pinder, pearl millet, and sorghum. The packages are labelled with instructions on the portion size per serving and the total daily serving. Administering these meals in a controlled hospital environment where the children are closely monitored, has enabled the children to gain between 4 to 10 grams daily.
Lukeman Bashir and his wife Halima, fled from Shadadi to Kontagora when bandits attacked their community in February 2022. Since their return to Shadadi, the couple, who lost their farmlands to the attack, have been unable to fend for their eight children, the youngest being six-week-old, Haliru. Their son had a large sore on his chest due to muscle wasting caused by malnutrition. They were at the Kontagora General Hospital for four weeks before Haliru fully recuperated. "I never thought my son would get better so quickly. When we arrived, he was severely underweight. But the fortified meals the good doctor gave us were quite helpful," said Bashir.
Each meal costs between 350 naira for a small pack, 1,600 naira for a medium pack and 1,800 naira for the big pack. Each child initially receives either nine small sized-packs, six medium sized-packs or three large-sized packs. More is given, if needed, until the child gets better. Amina Ishaya, who prepares the meals, says she sources the ingredients from the local market. "The good news is that mothers can find most of the ingredients in their communities," she added.
Dr Okutepa has, since 2019, self-funded and driven the production of these locally prepared fortified foods. Depending on the needs of the children, he spends between 50,000 naira to 100,000 naira monthly. So far, 634 malnourished children have received this cost effective but nutrition dense meals.
"Unfortunately, several of the children passed away before the treatment could take effect," said Rabiu Mohammed, a nurse at the hospital's Children Ward. "The project then naturally took shape as more and more refugee families started seeking medical help for their underweight or malnourished children."
"Dr Okutepa is also known to give cash gifts to mothers of malnourished children, educates them on the value of exclusively breastfeeding a child for six months and provides them with recipes for making nutritious supplementary foods from inexpensive, readily-available food in their community," she added.
By sheer determination
The initiative is refreshing as it is with a great deal of determination and very little financial support that Dr Okutepa and his team have been able to provide these fortified ready-to-use alternatives to the malnourished children under their care. It is currently sustained by whatever financial support Dr Okutepa can contribute, mostly from his salary. "Occasionally, he receives small private donations from colleagues and friends," Nurse Mohammed said. He initially tried to get the state government to fund the initiative but gave up as the State Nutrition Officer repeatedly informed him that there were no funds. Therefore, the future of the project is uncertain.
Discussing the burden of malnutrition in the state, Chairperson of the State's Committee on Food and Nutrition, Hajia Ramatu Umar, stated in 2021 that over 21,000 children under-2 in Mashegu and Mariga local government areas (LGAs) were suffering from stunting and wasting as a result of malnutrition. The 2018 Nigeria Demographic and Health Survey also revealed that 14.8% of children were wasted and 28.2% were stunted in Niger State.
The Niger State Policy on Food and Nutrition commits to employing interventions and approaches that will improve the nutritional status of people in the state. Among other things, the policy commits to creating an enabling environment for the local production of RUTF and ensuring adequate supply and provision of RUTF for the treatment of SAM and malnutrition among vulnerable children.
Developed in 2017, the existence of a policy on food and nutrition is a key milestone for improving nutrition in the state. For proper implementation there must be strong multisector coordination, particularly with the State Ministry of Finance, as funding, which includes sufficient budgetary allocation, and a timely release of funds is critical to ensure adequate implementation of the policy. However, there is currently no budget line to fund nutrition programmes.
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Local production of RUTF or similar products
In an interview that Nigeria Health Watch held with Shawn Baker, Chief Nutritionist for the U.S. Agency for International Development (USAID), he said that Nigeria has the local capacity to manufacture RUTF and the potential to produce enough for the West African region and even the rest of Africa.
Local production of RUTF or similar products should be encouraged as the global RUTF market is projected to become a multimillion US dollar market by 2028. Local production of RUTF or upscaling of what is already available locally, will not only tackle malnutrition, but it will also create jobs, and lead to economic growth in Nigeria.
"Until the government scales up financing for nutrition"
The team at the 'Out and In-patient Treatment of Malnourished Children' Unit are pleased with the substantial success recorded while administering the locally prepared nutrition-dense meals to the malnourished children in their care. However, they believe that they should not be an alternative to RUTFs as the meals are of lesser quality.
RUTFs contain peanuts, sugar, milk powder, oil, vitamins and minerals. The local alternatives do not contain these vital ingredients. This was a deliberate omission as not many rural dwellers can afford to add them to their meals.
In addition, RUTFs have a two-year shelf life, do not require refrigeration after opening and do not need to be mixed with water while being prepared, reducing the risk of children consuming contaminated water.
The locally made meals, on the other hand, go bad after a few weeks, especially when left open. They also must be prepared with water which increases the risk of contamination.
On his part, despite the funding and quality constraints, Dr. Okutepa is unfazed and has vowed to continue supporting malnourished children and their families "until the government scales up financing for nutrition... or I am unable to continue, for whatever reason."
