Malnutrition Is Cheating Its Survivors, and Africa’s Future

MICHAEL WINES
NYT, 28 December

SHIMIDER, Ethiopia — In this corrugated land of mahogany mountains and tan, parched valleys, it is hard to tell which is the greater scandal: the thousands of children malnutrition kills, or the thousands more it allows to survive.

Malnutrition still kills here, though Ethiopia’s infamous famines are in abeyance. In Wag Hamra alone, the northern area that includes Shimider, at least 10,000 children under age 5 died last year, thousands of them from malnutrition-related causes.

Yet almost half of Ethiopia’s children are malnourished, and most do not die. Some suffer a different fate. Robbed of vital nutrients as children, they grow up stunted and sickly, weaklings in a land that still runs on manual labor. Some become intellectually stunted adults, shorn of as many as 15 I.Q. points, unable to learn or even to concentrate, inclined to drop out of school early.

There are many children like this in the villages around Shimider. Nearly 6 in 10 are stunted; 10-year-olds can fail to top an adult’s belt buckle.

They are frequently sick: diarrhea, chronic coughs and worse are standard for toddlers here. Most disquieting, teachers say, many of the 775 children at Shimider Primary are below-average pupils — often well below.

“They fall asleep,” said Eteafraw Baro, a third-grade teacher at the school. “Their minds are slow, and they don’t grasp what you teach them, and they’re always behind in class.”

Their hunger is neither a temporary inconvenience nor a quick death sentence. Rather, it is a chronic, lifelong, irreversible handicap that scuttles their futures and cripples Ethiopia’s hopes to join the developed world.

“It is a barrier to improving our way of life,” said Dr. Girma Akalu, perhaps the nation’s leading nutrition expert. Ethiopia’s problem is sub-Saharan Africa’s curse. Five million African children under age 5 died last year — 40 percent of deaths worldwide — and malnutrition was a major contributor to half of those deaths. Sub-Saharan children under 5 died not only at 22 times the rate of children in wealthy nations, but also at twice the rate for the entire developing world.

But below the Sahara, 33 million more children under 5 are living with malnutrition. In United Nations surveys from 1995 to 2003, nearly half of sub-Saharan children under 5 were stunted or wasted, markers of malnutrition and harbingers of physical and mental problems.

The world mostly mourns the dead, not the survivors. Intellectual stunting is seldom obvious until it is too late.

Bleak as that may sound, the outlook for malnourished children in sub-Saharan Africa is better than in decades, thanks to an awakening to the issue — by selected governments, anyway.

South Africa provides nutrient-fortified flour to 30 million of its 46 million citizens. Nigeria adds vitamin A to flour, cooking oil and sugar.

Ethiopia’s government hopes to iodize all salt by year’s end. United Nations programs now cover three in four sub-Saharan children with twice-a-year doses of vitamin A supplements.

Ethiopia may, in fact, have the most comprehensive program in all Africa — a joint venture with United Nations agencies that regularly screens nearly half of its 14 million children under 5 for health and nutrition problems. Since 2004, the program has delivered vitamin A doses and deworming medicine to 9 in 10 youngsters, vaccinated millions against childhood diseases and delivered fortified food and nutrition education.

Unicef’s Ethiopia representative, Bjorn Ljungqvist, said the effort sprang from a disastrous 2003 drought in which global aid agencies fed 13.2 million Ethiopians — the most costly aid undertaking ever in Ethiopia.

When the aid effort ended, he said, international donors and government officials decided that “we have to ensure that we don’t get into this situation again.”

The program may be a model for Africa: similar ones try to improve youngsters’ health, but none, Dr. Ljungqvist said, addresses the nutritional deficiencies that leave children with lifelong disabilities. The effort saves 100,000 lives a year, by Unicef estimates. And because it focuses not just on handouts, but on preventive care and nutrition education, the effects could be lasting.

Beyond that, as African nations develop Western-style mass markets, with brand names and national distribution networks, sales of vitamin-fortified foods are slowly becoming common in urban areas, just as in the West decades ago.

But much of the continent has far to go.

Well over half of sub-Saharan children under 5 lack iron, vital to developing nervous systems, the Micronutrient Initiative, a Canadian research organization, reported in 2004. They often have trouble concentrating and coordinating brain signals with movements, like holding a pencil, that are crucial to education.

Another 3.5 million children lack sufficient iodine, which can lower a child’s I.Q. by 10 or more points. More than a half million suffer vitamin A deficiency, which cripples young immune systems; merely ensuring adequate vitamin A can lower child mortality by more than one- fifth. Children lacking vitamin B12, regularly measured nowhere in Africa, have impaired cognitive skills and do poorly on tests.

In most foods, these vital nutrients exist in traces — vitamins A and B12, iron, iodine, folic acid. Denied them in the womb and in infancy, children suffer irreversible brain and nervous-system damage, even if they appear well fed.

“Even trained people can’t always see them,” said Mark Fryars, the director of program services for the Micronutrient Initiative. “You may see a kid whose skin is very pale. You may go into a classroom where a child wanders off, or falls asleep, or doesn’t go out to play because he’s too tired. Multiply that into whole villages, and that translates into an impact on the society.”

In richer parts of the world, nutritional deficiencies are a nonissue. Three percent of American children are malnourished. American flour and cereals have been fortified with vitamins and iron — by law — since the 1930s.

In sub-Saharan Africa, however, lost productivity from vitamin and mineral deficiencies costs nations $2.3 billion a year, Unicef reports, and losses of productivity in Mozambique, Zambia and Malawi exceeded 1 percent of gross domestic product.

Many African children sometimes receive nutrient supplements, courtesy of the World Food Program, Unicef and charities. Still, donors cannot meet the need. In Ethiopia, for example, a venture between the government and United Nations agencies is caring for 20,000 acutely malnourished children at 100 sites.

“But we can count 70,000,” said Iqbal Kabir, the chief nutrition expert at Unicef offices in Addis Ababa, Ethiopia’s capital. “We can’t treat them all.”

Shimider is but a hundred or so stone and reed homes, one room each, in a mountain valley in the Amhara region, 250 miles north of Addis Ababa. The slopes here have been intensively farmed for thousands of years, and their soils are exhausted.

Twenty-two years ago, a famine here killed more than one million people. Today, hunger is measured in squandered lives.

Thirty percent of Amhara’s children under 5 are stunted, with another 26 percent severely stunted, evidence of lifelong, acute hunger. One in 15 pregnant women experiences night blindness, indicating vitamin A deficiency and a diet devoid of protein and red or yellow fruits and vegetables.

Among both malnourished children and their mothers, the impact of such privation is achingly evident.

One recent Sunday, Tewres Beram, a woman in her early 20s, carried her daughter Mekdes to a free immunization clinic. Mekdes, severely malnourished, sat suckling fruitlessly at her mother’s breast. “We don’t have enough food,” her mother said, “so there’s not enough milk to feed her.” A year old, Mekdes does not crawl. Her sister, 2, has barely begun to crawl. “Both of them are like little dead bodies,” their mother said.

Sirkalem Birhanu, 40, clasps Endalew, age 2 and unable even to hold up his head. “He’s always sick,” she said. Endalew has company, she said; his 13-year-old brother “is very tiny, and he loses weight.”
“And he’s always been sick,” she added.

And there is Berhane Gebeyew, 36, whose malnourished 18-month-old daughter, Genet, is a lump in her lap, despite receiving six months’ worth of fortified food last May from the governments.

Mrs. Gebeyew split the food among Genet and her four siblings, ages 6 to 15. “The other children, when they stare at my eyes, I give it to them,” she said.

She and her husband feed their children two daily meals of injera, a spongy flatbread of fermented barley, occasionally with four ounces of bean sauce. When the children attend Shimider Primary, each gets 10 ounces of vitamin-fortified meal mixed with cooking oil. But attendance is spotty, especially when they help harvest crops in November and December.

And by the time children reach school age, much of malnutrition’s damage has already been wrought.

Wondewosen Fekadu is the headmaster at Shimider Primary. Mr. Fekadu worked last year in Tseta, a lowland village where families eat better and drink milk. The difference in their students, he said, is striking. “Children there are relatively smarter and more active,” he said. “There are students here who are up to fourth grade and they cannot even read and write, even attentively following the classes.”

Three of Mrs. Gebeyew’s children attend Shimider Primary. Mogus, a 10-year-old third grader, is three and one-half feet tall — wide-eyed, sweet and flummoxed by academics.

“He’s on the poor level — very slow,” his teacher said. “He doesn’t give attention when I’m teaching. He doesn’t concentrate.” In a classroom of 60 children, Mogus ranks 46th.

Mulu, 13, her ribs prominent through rips in her green school dress, races from home to get to her beloved third-grade class. But Mulu is 47th in a class of 60.

Fifteen-year-old Yirgalem, about two inches taller than Mulu, has a teenager’s diffidence toward school. “It’s not that tough,” he said. His second-grade teachers differ. “When he comes to school, I don’t even think his mind is normal,” one of his teachers, Amelework Ejigu, said.

There is great promise that this region’s future youngsters will not be hobbled by mental disabilities. Virtually all nutritional deficiencies can be easily and cheaply prevented, sometimes for pennies per child, through programs like universal salt iodization, fortification of flour and semiannual doses of vitamins.

Such efforts already are under way in some nations, and they are a foundation of most United Nations children’s programs. But in just as many places, they remain a promise.

At Tefera Hailu Memorial Hospital in Sekota, across a mountain from Shimider, the nutrition ward’s 10 beds are filled with worried mothers and shrunken babies. Among them are Adna Berhanu and her 5-month-old son, Agnecheu.

Mrs. Berhanu’s huge goiter is decorated with blue tribal tattoos. Her skeletal baby is severely iodine deficient, surely impaired for life should he survive.

Although iodine deficiency is endemic in Amhara Province, “I’ve been here a year, and we have no iodine in this ward,” the nurse on duty said. Beyond a blood test to estimate iron content, the attending physician said, no one even analyzes children’s nutritional status. Such tests, he said, are luxuries.

“We focus on saving lives; that’s our long-term focus,” he said. “We can’t focus on what happens to them afterward.”