Kwashiorkor is back

In 1933, a British paediatrician, Cicely Williams, then working on the Gold Coast (now Ghana), described a syndrome in children, usually between the ages of six months and four years, who had been forced out of their mothers’ wombs. by the birth of another child, marked by the inability to gain weight, swelling of the hands and feet, and various skin changes. She named the condition “Kwashiorkor”, the word Ga meaning “the fallen child”. The condition was associated with feeding young infants and children poor quality foods. Four of the five children she described died. Since records of the disease began, the death rate from kwashiorkor and other forms of severe acute malnutrition in children has remained high. 20-30% of these children die, regardless of where they are cared for. Sometimes up to half of them die.

Other forms of severe acute malnutrition, as the World Health Organization currently calls it, are marasmus and marasmic kwashiorkor. These children present the definition of childhood destitution. Those with kwashiorkor look miserable and emaciated, with little more muscle in their buttocks and other body parts. Feet and legs are swollen and hair becomes scanty and falls out easily. The skin has various types of affectation, including cracks, cracks, peeling, ulcers and infections. Those with marasmus are severely emaciated, wise or old-man-like but not bloated. Marasmic-kwashiorkor exhibits a combination of marasmic and kwashiorkor characteristics. Severe tingling completes the spectrum of severe acute malnutrition

These children, for many reasons, are prone to infections which are often the immediate cause of death. But that, and other short-term issues, aren’t the only challenges these children face. Several studies have shown that those who survive later in life tend to have smaller head sizes and are not as intelligent as their peers who have never suffered from severe acute malnutrition. This intelligence deficit continues into adolescence. Additionally, they end up being shorter or shorter than their peers. Females grow up to have smaller pelvic sizes than their peers, preparing them for childbirth difficulties as adults. These are the ones who can continue to have obstructed labor as adult women.

Severe acute malnutrition was largely unheard of in Nigeria until the civil war, when hunger became a powerful instrument of war in our country. Thousands of children developed swollen legs, abdomens and faces, became emaciated, had misery written all over their faces, cried from hunger until they could cry no more and fell en masse on the edge of the way to the great beyond. Severely malnourished children have become the hallmark and face of the Nigerian civil war. Shortly after the war, we did not see these children again. Food and hope returned, and kwashiorkor only became known to a few doctors to whom the rare cases were referred. I was a medical student in the late 70s and early 80s. Suppose a child with kwashiorkor comes to the hospital, our teachers quickly send us to get the rarity. Besides the zeal and commitment of these great souls to teaching, I suspect that part of the urgency was due to the fact that no one could tell which of them would survive and for how long. Then came the mid-80s, and kwashiorkor was back with a vengeance. Our children’s wards again filled with infants and young children with shrunken faces, swollen legs and abdomens, with very few muscles clinging to their bones. It was the era of the “essential product”; we queued for a few cans of milk, sugar and chocolate drinks. As prices were pushed down by the military government of the day and traders were busy hoarding, swollen feet and legs were buried in droves underground. Then came another military government and introduced what it called the structural adjustment program. A few more swollen faces and legs went under the ground until things seemed to level off at a not so great number of swollen feet and legs. Then another civilian government came along, and we were promised “democracy dividends”. Debt relief has been obtained. To be honest things seemed to be improving and there seemed to be more food for the kids. The Child Survival Program was introduced by the World Health Organization: Growth Monitoring, Oral Rehydration. Therapy, breastfeeding, vaccination, family planning, women’s education and food security (which never came). The incidence of kwashiorkor has decreased. We had more hope for our children and therefore for our future. Nation of Nigeria, in the 2020s, kwashiorkor is back!!

Children and children’s services are good barometers of the state of the nation. Currently, only about one-fifth of children aged 0-23 months in our great country receive the minimum acceptable food they need. Across the country still, our children’s wards are filled with skinny buttocks, swollen feet and legs. We have come full circle. WHO and UNICEF estimate that two million children in Nigeria suffer from severe acute malnutrition, with the northern states of Nigeria being the most affected. Of these, only about 20% are achieved with the necessary treatment. If the mortality rate for these infants and children in the best treatment centers reaches 20-30%, I leave the nation wondering how many of these children are dying in our communities without being registered.

The tired-looking American professor of international health walked into our class (yes, we had them here at the time). He asked what was the cause of protein-energy malnutrition (the old name for severe acute malnutrition)? We told him about the classic, dysadaptation and other theories. He appeared unimpressed. After much discussion, he came out with one word, “POVERTY” and reminded us that malnutrition is a social disease. Malnutrition follows poverty. When poverty deepens, emaciated bodies, swollen legs and feet follow, that is a fact. Anyone in doubt that poverty has worsened in Nigeria should please visit our children’s hospital wards.

Other factors certainly contribute to this. The low rate of exclusive breastfeeding in the country, disruption of the food chain by insecurity, other natural and man-made disasters, childhood infections and recently the COVID-19 pandemic have contributed. If it is true that food supplies intended to relieve hunger at the height of the pandemic were diverted, add that to the list of causes for the resurgence of malnutrition and salute those who did so for their blind courage. Every naira or dollar stolen from national coffers, every kobo vanished and every high-rise building or private jet that comes from public funds adds to the number of emaciated bodies, swollen feet and hands in our children’s wards and those who die silently in our urban slums and villages. Think about it. The Russian-Ukrainian war disrupted the global food supply and insecurity in Nigeria did the same for the local food supply. The unprecedented rate of inflation and falling real incomes as the value of the naira continues to fall is recruiting children, even from middle-class families, into the ranks of the severely malnourished.

Only competent, honest and strategic economic management will prevent us from returning to the situation of civil war. Kwashiorkor, marasmus, marasmic kwashiorkor, or whatever you call it, is a disease of poverty, and Nigeria doesn’t have to be poor.

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Poverty, malnutrition, disease and death form a vicious circle. Malnutrition contributes to 45% of Nigerian child deaths. Those who survive severe malnutrition cannot realize their intellectual and physical potential. Climbing the social ladder out of poverty becomes difficult. These children are less likely to grow up to be physically fit to use sport as a pathway out of poverty. Girls grow up to be adolescents and young adults with higher risks of obstructed labor and its consequences. Hypergamy is a phenomenon where poor young women marry into the upper social class and escape poverty. It’s usually for the “prettier” and taller ones. Both are generally not attributes of young women who grew up malnourished.

The circle must be broken somewhere. UNICEF reports community management of acute malnutrition in northern Nigeria. In this programme, children who suffer from severe acute malnutrition are taken to a primary health center once a week and given ready-to-use therapeutic food to treat the disease. Treatment usually lasts about eight weeks with good results. Let’s hope for continuity and expansion in other parts of the country, but prevention is imperative. Efforts to encourage exclusive breastfeeding for the first six months of life and continued breastfeeding for two years or at least one year, improved complementary feeding practices, immunization, adequate management of diarrhea and other infections and family planning are essential. But poverty is the foundation of severe acute malnutrition. The eradication or, at least, the drastic reduction of poverty, must therefore be the basis of the solution. The link between corruption and poverty has been demonstrated time and time again. There are currently feverish levels of political activity in the country, and millions of dollars and naira are said to be spent. Let there be no less feverish activities towards the eradication of poverty. Let us be so embarrassed as a nation at the escalation of severe acute malnutrition that every available naira and kobo would be spent on eradicating poverty. Let the image of the child with atrophied muscles, swollen legs and cracked skin come to mind whenever we see a kobo of public funds. What happens in our air-conditioned offices affects our pediatric services. Kwashiorkor is back but doesn’t need to stay. Let’s think of our children.

Professor Ekanem from the Department of Pediatrics at the University of Calabar writes from Cross River State

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