Malnutrition: How diversion of supplement poses health burden in North

Despite huge availability of vitamin-enriched and  energy-boosting food supplement known as ready-to-use therapeutic food specially designed  to address acute malnutrition, many children suffering from the case don’t have access to it. This is against the backdrop of brazen illegal diversion and trading of the supplement; a trend that poses health burdens in the North, Daily […]

Despite huge availability of vitamin-enriched and  energy-boosting food supplement known as ready-to-use therapeutic food specially designed  to address acute malnutrition, many children suffering from the case don’t have access to it. This is against the backdrop of brazen illegal diversion and trading of the supplement; a trend that poses health burdens in the North, Daily Trust on Sunday reports. 

Ready-to-Use Therapeutic Food (RUTF), also known as plumpy nut, is an energy-boosting supplement and vitamin-enriched food that requires no preparation. It is specifically designed to treat acute malnutrition.

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It is prepared, procured and distributed to those who need it, mainly by multinational organisations, such as the United Nations Children’s Fund (UNICEF), Doctors Without Borders or Medicine Sans Frontiers (MSF) in French, national and state governments, as well as local non-governmental organisations.

But despite increased procurement volumes of the medicinal food supplement, many children suffering from severe malnutrition still don’t have access to it.

It is, however, seen on display for sale in some markets, on the streets, and even hawked from house to house in Katsina, Kano and Jigawa states.

 With all the efforts put in place by governments and other relevant stakeholders through taskforces, the unhealthy attitude of diversion persists.

 

Investigation revealed that perpetrators of this illegal business usually convince their retailers and hawkers of the danger of disclosing their sources of supply.

 It is also discovered that even in remote villages where the food supplement is sold, retailers, who are mostly housewives, are fully aware of what the food is and what it is meant for. They know it is an illegal business; and therefore, hardly disclose their sources of supply.

 In Jigawa State, the RUTF is sold in many towns, particularly those on the border with Niger Republic. It is sold in places like Maigatari, Babura and Birniwa. It is retailed and hawked in many towns and villages across the state.

At Garun Gabas town, Malam Madori Local Government Area of the state, a retailer, Malama Zainabu Yagana, who said she got her supply from the Republic of Niger through Nguru town in Yobe State, explained thus: “This is something meant for malnourished children, so it is illegal to sell.

 “The woman who supplies it to us will never disclose how and where she got it from. We give her the money and she will only say it is from Niger Republic. She usually tells us that it is as concealed as foreign rice or any other contraband because if it is seen it would be seized and the person will most likely be arrested.”

 Yagana said she purchased a carton of the commodity containing 150 sachets at the rate of N16,000 and sold each sachet at N120, making a profit of N2,000 per carton.

 Similarly, in Hadejia town, a retailer who didn’t want to disclose her name, said she got her supply from Potiskum and Damaturu, all in Yobe State.

 She explained that it was a relative who worked in a non-governmental organisation that introduced her to the business, and her consignment was way-billed to her, either from Damaturu or Potiskum.

“I send my money to the seller through commercial drivers and they bring it to me while I pay for the waybill. The cartons are usually emptied into sacks in order to avoid detection,” she said.

 Also, in Katsina, in order to conceal his source, a young man who sells the plumpy on the street, said his supply was from Madinah in Saudi Arabia. “My grandfather went to Madinah and supplied it from there. You can see Arabic inscriptions on it,” he said, smiling.

Another young man who sat next to him, however, said he got his purchases from Niger Republic, adding that he could supply whatever quantity needed.

 

Acute malnutrition hits over 7,000 Children — Official

 The executive secretary of the Katsina State Primary Healthcare Development Agency, Dr Shamsudeen Yahaya, recently said 7,271 out of 1.2 million children in the state were suffering from acute malnutrition. He also said 92,766 children, particularly those in rural communities across the 34 local government areas of the state, were battling with moderate form of malnutrition.

Yahaya, who was speaking in Katsayal community in Sandamu Local Government Area of the state during the distribution of locally made RUTF by the wife of the state governor, Dr Zakiyya Aminu Masari, noted that many children under the age of five years in the state were stunted.

Similarly, according to the UNICEF chief of Kano Field Office, Mr Maulid Warfa, the problems of food security and malnutrition were common among conflict-affected individuals and displaced populations all over the world.

“In northwestern Nigeria, banditry, cattle rustling, kidnapping and killings have been on the rise. 

“In Katsina State, settlements in local government areas such as Batsari, Safana and Dandume have been affected by such disasters, which have also significantly affected farming, trade and the overall economic status of people in the areas,” he said.

 Why we’re in Katsina over malnutrition – Doctors

 Hassan Famfoure, the representative of Doctors Without Borders, a France-based organisation working in Katsina, said they came to the state in February 2021 after an observation that there was an increased number of patients from the state going to Maradi in Niger Republic to access treatment on malnutrition.

“When we analysed the increased number of patients in Madarumfa, Maradi, our team realised that more than 40 per cent of them were from Nigeria, mainly Katsina State. We alerted the authorities and decided to make a survey and the results were very critical because we found out that there was high problem of malnutrition in the state.

“We came with a proposal to intervene in order to respond to that crisis, and since July, we started implementing nutrition activities for both in-patients and out-patients. 

“For the inpatients, we are at Kofar Soro, where we have a comprehensive healthcare facility, where we established a 100-bed capacity centre that admits patients. 

“For the outpatients, we are currently running five Ambulatory Therapeutic Feeding Centres (ATFCs), four of which are in Jibia Local Government, located in Magama, Daddara, Gurbin Magama and one other, while the fifth one is located at the Kofar Marusa area of Katsina metropolis,” he said.

He said that in the ATFCs alone, the organisation had over 4,000 patients that were followed up, while at the 100-bed in-patient, they admit an average of 300 patients monthly.

“Frankly speaking, the situation here in Katsina is very critical. Apart from the MSF, there is also Alima, another non-governmental organisation providing nutrition capacity in Kaita Local Government with over 2,000 patients.

“We are giving pumpy nuts; and considering the number of patients, you will realise that the quantity we supply here is very huge.

“Malnutrition is linked with lack of food, availability of good food, proper food for children. It is also linked with some diseases, such as malaria, measles and the like.

“So, talking about the diversion of plumpy nut, we learned about it and have informed the Ministry of Health about it. Our fear is that we can see it displayed everywhere in the market. 

“But that does not mean it is only coming from our side; we have other actors like Alima. We are also in Niger Republic. The UNICEF is also providing to the Ministry of Health.

“On our side, if you look at the number of patients we are dealing with, it will certainly lead to a huge quantity of plumpy nuts, but we have some tools in place for follow up and monitor. For example, the moment a child is admitted, we put a bracelet on his arm and ankle, with which we monitor, take measurement and record in his file on a weekly basis. 

“To be honest, it is difficult to divert our plumpy nut, but it is also possible because you cannot control everything, especially regarding the outpatients.

“One other way of ascertaining where it comes from is by checking the batch number; and we are informed that there is a taskforce in charge of preventing the diversion.

“Plumpy nut is really expensive, and from time to time we have to request for support from other partners; and currently, in Kano, there is a factory producing plumpy nut and we are also patronising it.

“We procure about 8,000 cartons at the rate of $US50,000, and that is to tell you how expensive it is.,” he said.

 In Kano, the intervention is taking place in 13 out of the 44 local government areas of the state. The issue of diversion is also rampant there.

The chairman of civil society organisations engaged in monitoring the distribution of the plumpy nuts, Malam Zakari Kano, said that from what they gathered, some health workers were involved in the diversion.

“It is sold in houses. You can even get it from tea sellers. Some grown-up healthy men will go to a tea seller, buy plumpy nut and use as a sandwich on their bread. 

“Sometimes, even a father will collect from what is given to his child because they consider it something nutritious and delicious.

“When we investigated, some of them said it was from health workers who are in charge of the distribution, particularly at the community management of acute malnutrition centres. 

“Here in Kano, we have 65 centres, five each in 13 local government areas. Other local government areas have to go to centres close to them.

“So, honestly, in Kano, the diversion is done mostly by health workers. I am not saying it is not coming from other places, but most of the vendors we spoke to told us that it was coming from health facilities,” he said.

 Malam Zakari said the best way to eliminate the problem of diversion was through effective monitoring on the part of government, as well as strong disciplinary action against those found wanting so as to deter others from engaging in the illegal business.

However, at one of the centres in Kano, the person in charge, Malam Isah Danjuma, said the problem was mostly through women who collect plumpy nuts for their children but ended up selling it.

 “It was discovered that some of the women were in the habit of taking their children to different centres just to collect and sell. When that was discovered, one of the measures taken was to harmonise the distribution date. 

 “It was done in such a way that those for first registration would do that and collect on Wednesday, while those with follow-up would do that on Friday. That only reduced the problem but could not eliminate it,” he said.

Malam Isah added that a lot was also coming from Niger Republic, according to investigations.

He, however, said the international business mogul, Aliko Dangote, had intervened in the state by adding 13 more local government areas to the 13 already engaged to make it 26.

 He said, “Out of the 13 added, he started with five, where he built nutrition centres, where some children can be admitted. He also renovated their staff quarters and sank boreholes. They have already taken off.”

 

 Dangote working to tame malnutrition

 In Kano also, the state government, with technical support from the UNICEF, as well as Dangote Foundation, is working towards taming malnutrition.

Hajiya Halima Musa Yakasai, nutrition officer in the state, said that initially, Kano State had to go as far as France, Kenya or South Africa to procure plumpy nuts, but with the establishment of a production centre in the state by a French-based company, Nutri Care, it had become a bit easier now.

 She said that with Dangote’s intervention and that of UNICEF in the 26 local government areas, more malnourished children would be covered, adding that the programme is capital intensive.

On the issue of diversion, she said their investigations revealed that the plumpy nut seen in the markets in Kano were mostly from northeastern states of Yobe, Borno and Adamawa, where there were a lot of internally displaced persons camps.

 “We have arrested a lot of people involved in selling plumpy nuts, and most of them confessed that it is either from Borno, Yobe or Adamawa. We have also found some of our health workers who engaged in the illegal business and dismissed them,” she said.

 Yobe, epicentre of pumpy nut trading

 In Yobe State, a staff of an international donor agency, Mr Liman Bashir, said their investigation revealed that the diversion of plumpy nuts was done mostly in the rural areas with connivance between people in charge of health facilities and nutrition officers.

“It is unfortunate that people who are better informed on the efficacy of the product in treating malnourished children and the implication of diverting it will still engage in the illicit business at the detriment of the children they are supposed to care for.

 “It is very difficult to detect how they do it because they are very smart. But governments need to take the issue more seriously if it is to be tackled,” he said.

 At Potiskum, our investigator was offered two cartons of 150 sachets each at the rate of N13,000 per carton. The dealer, a woman, also claimed that she got her supply from Niger Republic, adding that though it was difficult to cross it over to Nigeria, a large quantity could be secured if there is the need.

From the foregoing, four major ways are identified, through which the RUTF is diverted into local markets. These ways include those imported from Niger Republic; those diverted from displaced persons’ camps, particularly in the northeastern states of Borno, Yobe and Adamawa; those diverted from the centres by health workers and those collected for children but sold by their supposed caregivers (parents).

 On their part, a non-governmental organisation, Save the Children International (SCI), also confirmed that from their investigation, the diversion was mostly done from the health facilities where it is distributed.

One of their coordinators in the North, Hajiya Murjanatu Kabir said, “At the centres, some of the children enrolled are not actually qualified, but they will enroll them just to cart away the plumpy nuts.

 “There was a time a health worker in charge of a centre was arrested with 50 cartons of RUTF. So, tell me if only one person could do that, how much more is done across all the centres we have?

 “Sometimes they will enroll a child but give his caregivers half the quantity of what they are supposed to get and divert the remaining half. There are a lot of issues concerning RUTF, honestly.”

Mrs Kabir added that sometimes parents would register their children at different centres, to the extent of forcefully cleaning the indelible marker used as a sign of registration on the fingernails of the children.

She also said some women were in the habit of ‘lending’ to children just to collect the plumpy nuts, while others gave their children tamarind soaked in water, just for them to develop diarrhea so that they would be enrolled.

 Consequences of diversion/illegal trading

 There are huge negative effects attached to the unwholesome diversion of the product meant solely for the treatment of malnourished children

Recently, the United States Soy (US Soy) declared that the high rate of protein deficiency in Nigeria had become a national pandemic and a huge drain on the country’s human capital.

No fewer than 59million Nigerians are macronutrient deficient and about 45 per cent of deaths among children under the age of five are linked to malnutrition, according to Food and Agriculture Organisation (FAO).

According to various researches, protein is a basic nutrient needed for the development, upkeep and repair of body cells.

Protein deficiency in Nigeria poses not only a major health burden but also stunting, mental hindrance (especially in infants), surliness and crankiness.

 U.S. SOY The country representative of US Soy for Nigeria and the sub-Saharan Africa, Dr Michael David, while expressing worry at the fourth Soy Excellence Centre (SEC) Advisory Council meeting, which was held in Lagos, lamented the low protein consumption across Nigeria, with a protein per capita daily intake lower than global standard.

He said that to overcome this challenge, the Nigerian government had the leading role to play, but the private sector, like US Soy, also play a critical role in ensuring that Nigeria overcomes the lingering problem of protein deficiency.

One of the quick ways to help check the problem of malnutrition, particularly in children from six months to adolescents suffering from severe malnutrition, is the provision of the RUTF, if properly administered.

According to the American Journal of Clinical Nutrition, 98 per cent of children treated with RUTF were well-nourished after six months, and 96 per cent were well-nourished after a year. The first 1,000 days of a child’s life are crucial and can determine much of their growth development.

 Poverty as one of the reasons 

 Mr Famfoure of the MSF said some of the caretakers (mothers) were poor, and malnutrition actually affects poor people. “If you look at a woman that has up to six children to take care of, you should know that it is not easy to feed them all, so selling some of the plumpy nuts to take care of other needs can be a source of having it in the local market, and it is difficult on our side to monitor the situation,” he said.

 Similarly, Mrs Kabir of the SCI said some mothers would sell part of the RUTF given to them to be able to transport themselves back home, which is an indication of how poor they are.

On his part, Malam Danjuma said some women who sold the plumpy nuts were doing so as a result of poverty because there are other challenges to deal with, while others simply turned it into a business.

Liman Bashir, who also concurred that some women engaged in selling the RUTF out of poverty, however, strongly disagreed that poverty pushed health workers to compromise. He said they were one of the best paid workers in the country.

 Wrong usage and its implications

 Murjanatu Kabir said different people used it for different reasons. She said it was discovered that some men used the plumpy nut as an aphrodisiac because they believe it enhances sex, while healthy children eat it as snack. Most women also use it as groundnut paste in their soups.

“The implication is that it is not ordinary groundnut and soybeans as some believe, it is medicine and has some additives. It can also lead to other health issues, such as obesity when well-nourished people take it,” she said.

 Balarabe Ibrahim, a health worker in Jigawa State said, “Some people buy and mix it with milk and take as food, while some children add sugar to it and consume. It is hawked here like ordinary groundnut.”

 Way forward

 Some suggestions were offered on how the problem of diversion of RUTF could be minimised.

Mrs Kabir said, “The best way to make the process more transparent is through traditional and religious leaders. Train them, let them know the enrolment and discharge procedure, let them also know the health implications of the bad attitude of diversion. If that is done, I believe it would reduce.

 “Another way is to localise the production so that it will not be ready to use, in such a way that people will no longer see it as snack but medicine for malnourished children,” she added.

 On his part, Mr Famfoure said there was the need for government and all relevant stakeholders to scale up surveillance to prevent the menace.

“It is very nutritious and effective in curing malnutrition, in such a way that within three weeks, you see tremendous improvement in a child. I, therefore, advise us all to join hands to prevent diversion of the supplement.”

This report was supported by the Daily Trust Foundation with funding from the MacArthur Foundation