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September 20, 2020

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How Boko Haram insurgency worsened malnutrition, immunisation in Nigeria’s northeast

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Over the past 10 years, humanitarian crises in Northeast Nigerian states of Borno, Adamawa and Yobe has caused hostilities between non-state armed insurgency groups and government security forces.

The crisis, which has affected men and women alike, has resulted in widespread displacement, infrastructure destruction, and the collapse of basic social services, including nutrition and immunisation.

With an estimated population of about 13 million, the ongoing conflict and displacements have resulted in disrupted livelihoods, food insecurity and overcrowding, which increase the risks for malnutrition, related comorbidities and mortality within the vulnerable affected populations.

Data gathered by reputable organisations since the crisis started shows that the two key areas of nutrition and immunisation have been extremely affected by activities of insurgents in the region.

This data story reviews available statistics on nutrition and immunisation and then presents the current reality of residents, to show the trend the two have taken since 2009.

Nutrition coverage

Nutrition badly affected

A five-year study, between 2009 and 2014, conducted by the National Population Commission (NPC) and ICF International, a global consulting and technology services company, shows that the prevalence of stunting in these states increases with age, culminating at 46 per cent among children between 24–35 months.

Stunting prevalence

Stunting is an impaired growth and development that children experience as a result of poor nutrition, repeated infection, and inadequate psychosocial stimulation.

According to the World Health Organisation (WHO), the percentage of children stunted, wasted, and underweight are equal to the specific numerators divided by the appropriate denominators and multiplied by 100.

While stunting prevalence has improved since 2008, the extent of acute malnutrition (wasting or low weight-for-height) has worsened, increasing from 14 per cent in 2008 to 18 per cent in 2013 among children under five years, a result of the insurgency activities in the region. This could have been averted if there was enough supply of consumables for the children (0-59 months) in the region.

Looking further at available data, the 2015 National Nutrition and Health Survey, shows the estimates of global acute malnutrition; which found 10.9 per cent in Yobe, 11.5 per cent in Borno, and 7.1 per cent in Adamawa.

Nutrition coverage

The Health and Nutrition Survey was first launched in 2010 by the Nigeria Bureau of Statistics and National Population Commission with the support of UNICEF. The survey was set up to assess the nutrition and health situation at the state level, complementing Multiple Indicator Cluster Survey and Demographic Health Survey data and providing data to populate state scorecards for advocacy.

In 2016, a state of emergency was declared on nutrition in Borno after a small-scale SMART survey was conducted in the local government areas (LGAs) of Jere, Kaga, Konduga, and Monguno town in Borno State, between April and August 2016 which documented that the prevalence of global acute malnutrition (GAM) ranges between 13.0-27.3 per cent.

Global Acute Malnutrition (GAM) is declared an emergency when the threshold is above 10 per cent. The severity of the situation is considered to be of high public health concern and immediate actions must be taken.

The UNHCR standard is < 10 per cent, meaning that when GAM is less than 10 per cent in a given population, the severity of the situation is considered to be of low or medium public health concern but when GAM is 10 per cent or more, the severity of the situation is considered to be of high public health concern and immediate actions must be taken

In data extracted from the Nutrition and Food Security Surveillance round 8 report which was carried out in December 2019, the overall acute malnutrition prevalence at the state level is 11.5 per cent in Yobe, 8.1 per cent in Borno, and 7.2 per cent in Adamawa. The current levels of malnutrition are aggravated by the ongoing conflict in the region, food insecurity and inadequate dietary intake.

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But, how do these data translate in the lives of residents of this troubled region?

‘Our stories’ – mothers who lost children to malnutrition

A look at the situation on the ground gave a human verification to these data. In a bid to document the reality, PREMIUM TIMES visited the affected states to talk to residents.

In Borno, Fati Ibrahim, a 40-year-old from Gwoza, said she lost her three years old son to hunger and nutrition.

“When Boko Haram gunmen invaded Gwoza in 2010, we had to go to the top of the rocky mountains to take refuge. There, we spent so many days. There was no decent food to eat. The children were falling sick, and there was nothing to provide.

“We later moved down to a village near Madagali. My little child, Alaji, became so lean, just like many of the children, he later died. So many children died also. A medical officer said probably the wild cassava root tuber we dug in the bush to cook and give them as food was too harsh for their weak bodies. So, the children began to vomit and pass watery stool until most of them died. (Sobs…tears).”

Ladidi Usman, a 35-year-old displaced person from Baga, said she lost three out of the eleven children she has given birth to while in the IDP camp in Maiduguri.

“Three of my children died at a tender age due to lack of proper nutrition. After our displacement, we spent days in the bush. Many children died because of hunger. I lost a child on the way. But two of my children died here in the camp due to malnutrition. One was before the age of 12 months, and the other one died some weeks after birth. At that time, I too was malnourished and sick.

“The cases of malnutrition were not common, so medication for it was not a priority until when there was an outbreak in Bama, that was how we began to get food.”

Similarly, in a 2018 report by UNICEF on the state of nutrition in northeast Nigeria, the report shows that in the three states of Adamawa, Yobe and Borno that have been affected by the ongoing conflict, one in every five children was severely malnourished in 2018.

An estimated 940,000 children aged six to 59 months across these states were acutely malnourished; 440,000 with Severe Acute Malnutrition and 500,000 with Moderate Acute Malnutrition.

In a study between September 2019 and February 2020, the findings showed that there are 921,618 of the 2,647,302 number of children between six-59 months in Adamawa, Yobe and Borno who are acutely malnourished. In North-East Nigeria, the Severe Acute Malnutrition stands at 288,299; whilst the Moderate Acute Malnutrition is 633,319.

In Yobe, Ladi Buba, a 36 years old mother of five children said she lost her second child to malnutrition some years back when Boko Haram displaced her family from Goneri in Gujba local government area.

“The situation was bad, and our children bore the brunt of the pains. Hunger was everywhere, and children became malnourished. I lost a child to an unknown illness, but later the Médecins Sans Frontières people came in to say it was because of malnutrition that children are falling sick and dying.”

The experience was not different for Grace Yohanna, a 28 years old internally displaced woman at Malkovi Open Camp. She said she was fully malnourished when she had her second pregnancy.

“Boko Haram attacked our village in Madagali, we all abandoned our things back home and fled to Yola. I almost lost the pregnancy while running, and there was nothing good to eat there in the camp. When I eventually delivered the baby, with low-birth-weight, the doctors later said it was due to severe anaemia that I suffered during the pregnancy. The baby later died (tears).”

How immunisation fared

Immunisation coverage in Nigeria has been abysmally low.

Immunisation is administered to children in the early stages of growth and development to prevent mortality and disability as well as to eradicate preventable diseases such as tuberculosis, yellow fever, polio, measles and hepatitis. It also provides a solid ground for Universal Health Care (UHC) to be achieved.

According to UNICEF and WHO guidelines, every child is expected to receive a bacillus Calmette-Guerin (BCG) vaccination to protect against tuberculosis, three doses of diphtheria (DPT) to protect against diphtheria, pertussis and tetanus, three doses of the polio vaccine, and a measles vaccination by the age of 12 months. Caregivers were asked to provide vaccination cards for children under the age of five.

In a 2011 Multiple Indicator Cluster Survey (MICS) report by the federal government, in partnership with international NGOs, it was observed that the percentage of children (12-23 months ) vaccinated against polio is higher than that of DPT and measles. For instance, 73 per cent of children were vaccinated for polio1 whereas only 53 per cent for DPT1 and only 50 per cent for measles.

Immunization

In Adamawa State, 53 per cent of children (aged 12-23 months) received polio vaccination at birth, 78 per cent (Polio1), 65 per cent (Polio2) and 50 per cent (Polio3). 61 per cent received DPT1 vaccination, 66 per cent (DPT2) and 48 per cent (DPT3). 68 per cent were vaccinated against measles.

In Borno State, the figures vary greatly from Adamawa, with only 11 per cent of children aged between 12-23 months received polio vaccination at birth, 49 per cent (Polio1), 42 per cent (Polio2) and 22 per cent (Polio3). The percentage of children who received DPT1 vaccination is 25 per cent, while 21 per cent received DPT2 and 14 per cent received DPT3. 23 per cent were vaccinated against measles.

In Yobe State, 15 per cent of the children received polio vaccination at birth while 67 per cent (Polio1), 60 per cent (Polio2) and 49 per cent (Polio3). 27 per cent received DPT1 vaccination, 20 per cent (DPT2) and 13 per cent (DPT3) vaccination. 31 per cent were vaccinated against measles.

What mothers said

Zainab Ali Goni shared her experience in Borno. The 26-year-old mother of four children, who lived in a remote village near Gajigana in Magumeri Local Government said the community was cut off from access to medical healthcare due to Boko Haram attacks.

“I had never had any regular vaccination for two of my children when they were in our hamlet; all we gave the children were local herbs whenever they were sick. During the Boko Haram occupation of communities, many children died. My first contact with orthodox medication like routine vaccines was last year when we fled our villages and arrived in Maiduguri,” she said in Hausa.

A larger proportion of children who received full immunisation were found to reside in urban areas of the states.

According to the milestones of the Polio Eradication and Endgame Strategic Plan 2013–2018, poliovirus transmission was to be stopped globally by the end of 2014.

The country reported 53 people with poliovirus in 2018, 46 (86.8 per cent) in the northern states of Bauchi, Borno, Kano and Yobe, and five people with vaccine-derived poliovirus isolated from Borno and Adamawa states. Most were children from poor, rural families living in areas deemed hard-to-reach due to distance or geography.

The study, conducted between June 2014 and September 2016, revealed that only 62,758 children (0-11 months) in Borno State were fully oral polio vaccine immunised while 33,049 children (0-11 months) in Yobe received full polio vaccination.

According to the World Health Organisation (WHO), as of 2016, the under-five mortality rate in Nigeria was estimated at 104.3 deaths per 1000 live births. This represents a reduction since 1990 when the country reported 212.9 under-5 deaths per 1000 live births.

The national coverage of DTP3 immunisation coverage among one-year-olds in Nigeria was 39 per cent and this was strongly associated with economic status and mother’s education.

The report noted that children in female-headed households had a 1.4 times higher probability of immunization than children in male-headed households.

In another 2016/17 Multiple Indicator Cluster Survey commissioned by the National Primary Healthcare Development Agency (NPHCDA) and conducted by the National Bureau of Statistics (NBS) in 2016, 6,268 children aged between 12-23 months across 4000 households were enrolled.

The study showed that one in two children receive 1st dose of pentavalent vaccine while 42 per cent (4 out of 10) children do not receive vaccines from the health system and 42 per cent start but do not complete the three-dose series of penta 3. 80 per cent of children aged 12-23 months in the North East do not receive all immunisations.

Only one in four children in this region have child health cards, implying that health workers do not have the information they need to make good decisions on vaccination for children.

Adamawa State had only 29 per cent of children who received full vaccination. 41 per cent were partially vaccinated, 30 per cent were not vaccinated while only 45 per cent have a child health card.

In Borno State, 31 per cent received full vaccination, 56 per cent partially vaccinated, 13 per cent no vaccination and only 33 per cent have a child health card. In Yobe State, 7 per cent were fully vaccinated, 13 per cent partially vaccinated, 80 per cent no vaccinated were recorded and only 7 per cent have a child health card.

Ya’gana Abba, a 29 years old housewife, who currently nurses a seven months old child from Yobe state, said her two children became sick and she had to take them to the clinic in Gujba where she was told they were ill because they did not get the routine immunisation.

“When we were displaced by Boko Haram about five years ago, we all fled to Damaturu where we camped at a Camp, I was pregnant then, and my husband is a poor farmer – we had nothing.”

“I gave birth to my first and second child in three years, they were unable to get the routine immunisation in full. After returning to Gujba the children became sick, they said maybe it was due to change of weather; but we were later told it was malnutrition.”

In a comparative analysis between the MICS report of 2011 with the 2016 report, Adamawa, Borno and Yobe states recorded a significant change in the percentage of children (12-23 months) who received vaccination for polio and measles.

For Adamawa State, 54 per cent of children were vaccinated against polio at birth, 60 per cent (Polio1), 50 per cent(Polio3) and 40 per cent (Polio3). Only 49 per cent of children were vaccinated against measles. This figure shows a drop in the number of children enrolled for immunisation from 2011.

The World Health Organisation has certified Nigeria polio-free, making the whole of Africa free from the disease endemic after three consecutive years without an outbreak.

In Borno State, more children received polio and measles vaccination compared to the 2011 report. 66 per cent were vaccinated against polio at birth, 69 per cent (Polio1), 51 per cent (Polio2) and 41 per cent (Polio3). 58 per cent were vaccinated against measles.

Yobe State also witnessed a drop in the number of children vaccinated against measles and polio. Only 12 per cent of received polio vaccination at birth, 15 per cent (Polio1), 13 per cent (Polio2) and 9 per cent (Polio3). 14 per cent of children received vaccination against measles.

To curb the menace of malnutrition in Nigeria, the vice-president, Yemi Osinbajo, in a statement received by PREMIUM TIMES during the 2020 virtual conference organised by the Aisha Buhari Foundation in collaboration with development partners, said that; “There has been an increased investment of about N3.8 billion by Federal and State governments, especially for the procurement of Ready-to-Use Therapeutic Foods (RUTF).”

He also spoke on the “revitalisation of the Primary Health Care System with nutrition as the primary focus, the promotion of optimum breastfeeding and improved quality of complementary food.”

Why problem will persist – Experts

Chika Offor, the lead at Vaccine Network for Disease Control, a non-profit organisation dedicated to changing the face of health and education in Nigeria, said the precarious situation in the northeast makes it difficult to access for health workers.

She further said, “Hard to reach places in the North East especially areas devastated by insurgency and are worst hit when it comes to immunization services because the health workers put their lives at risk when they go to such places and some are even killed.

“Placing this humanitarian challenge alongside the COVID-19 pandemic, immunisation coverage becomes a losing battle, until insurgency stops, safe vaccines won’t be made accessible to all, there is very little anyone can do to increase coverage.”

“Please note that until vaccines are utilized by those that need them, before we can claim to have succeeded.”

In her recommendation, Ms Offor suggested that “the government should increase budgetary release for immunization and provision of logistics including solar energy to strengthen the cold chain and reduce over-reliance on donors.”

Also, she said the government should partner with the private sector to fill the gap in immunisation. For nutrition, she said the government should partner with farmers to help in producing ready to use therapeutic food.

A development consultant, Philip Olayoku, blamed “the regulation by the government and military” which, “has restricted the presence of aid workers to some of the areas in the affected states. This has made the coverage of immunisation not stable and also contributed to the number of malnourished children.”

Also, “the presence of Boko Haram in some of those communities has hindered the communities from benefiting from aid from both international bodies and locals,” he said.

Support for this report was provided by Premium Times Centre for Investigative Journalism, with funding support from Free Press Unlimited



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