Rage Of A Silent, Invisible Killer Called Malnutrition - Why Shining India Is In Grip Of An Epic Calamity
Hunger-Struck Photograph by Usha Ramesh
It’s a crisis that hides in plain sight. And Prime Minister Narendra Modi singles it out in his radio talks, from the ramparts of the Lal Qilla, for his 49.3 million followers on Twitter. He hammers home his impatience for the scourge to go away: “Main bechain hoon, main besabr hoon, main vyakul hoon” and pledges a new tryst with destiny: a malnutrition-free India by 2022. A new national lexicon is gaining ground for something that isn’t often in the news.
At the heart of global geopolitics, India is an emerging superpower at 72. But away from the spotlights, here starvation stalks, families battle chronic hunger to stay alive, lack of food starts from the womb, underweight mothers give birth to undersized children, while low immunity snuffs out vulnerable lives. Five years into power, the NDA government faces its toughest challenge. And now, the Vice President of India, Venkaiah Naidu, has sounded out a clarion call for action: “India needs a nutrition revolution.”
Ruby Devi stays put in a darkened room. Neighbours come calling, to drag her out of that corner, to eat, feed her son or breastfeed her daughter. She talks about her husband, Jhingru Bhuiyan’s year-long battle with stroke and paralysis, repeated attempts to get a ration card, inability to buy food or medicines, months of eating just rice, days of having not even a grain at home, the unlit chullah, loans, begging and his death. No expression, no tears, no anger. But as you take leave, she comes alive: “What will happen to us? Can you ask the sarkar for free food? A ration card?”
Sometimes, some places fall off the map. Dondagada village in Jharkhand, hidden in the maze of undulating hills, tall trees and red mud tracks of Chatra taluk, is one such. Sometimes people, too, fall off the grid of visibility. The family of Bhuiyan, the 40-year-old Dalit who died hungry and ill on July 16, is one such. Faces among 19 crore Indians who sleep hungry every night, among one-third of the world’s malnourished, and 25 lakh citizens who die of hunger-related causes every year. A disquieting presence amidst India’s new plenty—consumed by crushing poverty, wracked by malnutrition, inhibited from reaching full potential. How free are they as India turns 72?
She was appointed anganwadi worker under the ICDS scheme in September 2014. Her commitment reflects from the distance she has been covering from her home in Greater Noida to Nardan Basti, south Delhi, for work every day since December 2015. The mother of two has been teaching children below six and love to work with kids in this age group. This love motivated her to become an anganwadi worker.
Bhadumari village of Vidarbha in Maharashtra lies in the foothills of the Pandharkawada ranges. On a normal day, bright-eyed, barefoot children in school uniform sing-song, “Namaste.” But none of them are four-feet-two-inches tall yet, the ideal height for an eight-year-old mandated by the World Health Organisation (WHO). Most of them have sabzi with roti or rice at home, but love coming to school for the twice-weekly eggs they get. What else do they like? Fruits, they say: jamun, sitaphal, narangi. Ask them how often they eat fruits, they fall silent. Ask around the village and no mother mentions malnutrition to be an issue.
One in three children is stunted in India, too short for their age. One in five Indian children suffers from wasting, too thin for their height. One in four is underweight, too thin for one’s age, reports the Global Hunger Index 2018. “The problem with malnutrition is that it’s not visible,” says Shawn K. Baker, director of nutrition, Global Development Program, Bill & Melinda Gates Foundation. “Be it iron deficiency or of vitamin A, malnutrition is almost always hidden.” Especially, when almost every child is undernourished and small, it ceases to be a “problem”. What’s worrying is the havoc that malnutrition can cause to a child’s cognitive abilities, brain development, health and productivity—often irreversibly—starting in the first two years of life.
Ninety kilometres from Lucknow, the road leads up to Sitapur district of Uttar Pradesh. The slow meandering Gomti river keeps pace. Named after Sita of Ramayana, the area takes pride in its epic legacy. But right now, it’s a cause for worry: Sitapur is among 10 districts in the country that face the highest prevalence of malnutrition. Sitapur also tops in teen marriage and pregnancy: over 36 per cent married women are adolescents, while 8 per cent of the 15-19 age group are already mothers—much higher than the state and national average. Here, just 16 per cent girls get to study beyond class 10.
It is the secret story of India. Three-quarters of the world’s teenage births take place in India. New research shows how the health of children born to adolescent mothers is far inferior to those born to adult mothers (The Lancet Child & Adolescent Health, July 2019). A 2015 study from the Harvard T.H. Chan School of Public Health pinpoints the five most important predictors of childhood malnourishment, three of which have a direct link to mothers: maternal underweight, short maternal stature, a mother with no education, extreme poverty and poor dietary diversity. “Undernourished girls become undernourished mothers, who in turn give birth to low-weight babies, perpetuating a vicious cycle,” says Basanta Kumar Kar, country director at Project Concern International.
Doctors across the country are analysing mental maps of communities to understand malnutrition. What they find is an eye-opener: misconceptions, myths and malpractices in the name of customs and traditions, often dictated by elderly women of the household. A team from King George’s Medical University, Lucknow, report how in Sitapur, Hardoi and Barabanki areas newborns are routinely denied colostrum, the first milk that provides immunity for life, and fed with meals of honey, ghutti (made of herbs, additives and honey), water, sugar-water or animal milk instead of mother’s milk in the first few days.
Dr M.V. Ramana Rao of SVS Medical College Hospital, Telangana, shows that the baby is not given to the mother in 90 per cent of deliveries, largely due to traditional family practice of first wiping and cleaning the baby before passing it on to a senior family member. It is the family’s decision to throw away the colostrum (the first stage of breast milk that’s essential for a child’s immunity), as something dirty and unhealthy in most cases, or giving the baby feeds or formula milk as the first feed, instead of breastmilk.
When Dr Manjit Kaur Bal first saw the shrunken duo—a mother and child—she was shocked. The child couldn’t hold his head up because he was so malnourished and the mother was hardly in a better state to take care of him or of herself. As the leader of the Samerth Charitable Trust in Chhattisgarh, Bal has worked for long with some of India’s ‘particularly vulnerable tribal groups’—people wracked by poverty and hunger, dissociated from development processes, displaced from habitats and livelihood by depleting forests and encroachment.
The Melghat region, comprising Dharni and Chikhaldhara blocks, in Amravati district has a tiger reserve in its vicinity. It also has the highest malnutrition and infant mortality cases. Vidhale conducts several community activities to address malnutrition, such as rallies, cleanliness drives, festive events, and fosters a competitive environment through the Mata Samitee.
“The tribal food basket has always been diverse and nutritious, including maize, minor millets like kodo and kutki, oil seeds like ramtila, along with fruits, leaves, rhizomes, mushrooms, meat and fish,” says Bal. “We have pushed them out of their complementary relationship with ecology, way of life and time-tested nutrition.”
Concerned with the critical condition of the mother and child, Bal took them to a nutrition rehabilitation centre, government outlets where severe acute malnourished children below five years are admitted with their mothers for treatment. But they escaped within a few days. When Bal caught up with her, the mother said, “The rains are coming. There’s a lot of work in the fields. If I stay away now, my whole family will miss out on food for a year.” Does nutrition matter when hunger pangs hurt? “Even today, we offer minimum support price to paddy, not to nutritious millets that sustained people for thousands of years,” she says. “In 72 years, we have changed people’s food basket. It will not be easy to give their nutrition back to them.”
“It’s a man-made crisis,” says Balram, advisor to the Supreme Court on right to food, in Ranchi. Until the 1960s, India had a sustainable agricultural system and natural food security, explains the activist who worked closely with Jayaprakash Narayan’s movement in Bihar. People grew whatever they needed, or gathered from the surroundings—weeds, herbs, fruits, fish, livestock. The consumption of traditional coarse grains, pulses and millets, rich sources of vegetable protein with balanced amino acid profile, was exceptionally large.
The landscape changed from the 1970s, in the wake of the green revolution. Focused entirely on wheat and rice, successive governments promoted quick adoption of technology, high-yielding grains, intensive farming, chemical fertilisers and price assurance. But pulses and millets, Indian diet staples and inexpensive sources of energy and protein, were neglected. A host of indigenous grains, seeds and millets disappeared, while production of pulses declined, as prices shot up. It led to a fundamental change in the way people ate, putting small farmers at the mercy of large commercial farmers, and dissolving the idea of village community. “From around the mid-1990s, small farmer suicides and starvation deaths started getting reported,” Balram recalls.
“The world and India so far has focused on food security and we have achieved a lot,” says Purvi Mehta, Head of Asia for Agriculture at the Bill and Melinda Gates Foundation. “Having reached that hard-earned goal, the next step is tackling malnutrition,” she says. The impact of the word, however, goes beyond hunger and health—about 40 per cent of school absence in rural India is attributed to only one factor: malnutrition. Same is the reason behind about 30 per cent of absence of labourers in rural India’s workforce, Mehta points out.
CAN HUNGER END?
The Sustainable Development Goals, driven by the United Nations and adopted by all member states, talk of ending hunger by 2030. The economic toll of malnutrition is heavy—with Africa and Asia losing an estimated 11 per cent of GDP every year to it from productivity loss—but the cost of eliminating hunger will also be heavy, say experts (see graphic, p.56). And the cost will be significantly higher for high-burden countries such as India. According to a recent report by the UN Food and Agriculture Organisation (FAO), $267 billion will be required per year from 2016 to 2030.
India’s response is the POSHAN (Prime Minister’s Overarching Scheme for Holistic Nourishment) Abhiyaan or the National Nutrition Mission, set up with a three-year budget of Rs 9,046.17 crore starting 2017-18. A look at the state-wise data reveals that of Rs 3,142.17 crore released to states until March 2019, just Rs 569.92 crores were utilised. The fund remains under-utilised in a number of states: West Bengal, Odisha, Goa, Karnataka, Bihar, Maharashtra, Jharkhand, Punjab, Kerala, Assam, Delhi and Haryana.
She is a postgraduate working in Dulawato Ka Guda village, Badgaon block of Udaipur. During visits to different homes in the area, she came to know of two pregnant women who were not registered for ante-natal care at the health centre. Their mothers-in-law were not allowing them. So Garg met the moms-in-law and convinced them about the care. She makes it a point to ensure everyone gets the benefit of the scheme.
“Whenever you think of the PM, be it to criticise or to compliment, think of POSHAN Mission and not Narendra Modi.” On March 8, 2018, when the PM launched POSHAN Abhiyaan in the small town of Jhunjhunu in Rajasthan, his dramatic words had nutrition gurus across the country sit up and take note. At the end of the day, malnutrition can be tackled only if countries have the political will. “Nutrition is no longer a sectoral concern,” says Hisham Mundol, executive director, Children’s Investment Fund Foundation. “Nutrition is an economic, social justice and political issue.”
To senior bureaucrat and former mission director of Poshan Abhiyaan, Dr Rajesh Kumar, India always had malnutrition on its radar. Two of the world’s earliest and largest schemes to reduce malnutrition in children—Integrated Child Development Services (ICDS) in 1975 and Mid-Day Meals in 1962—were launched by India, apart from a range of 21 policy options on malnutrition since Independence. “But in 72 years, governments have changed, fallen asleep, woken up, on and off,” adds Kumar. “The focus on nutrition has waxed and waned accordingly.”
The drumbeats of shame started rolling from 2007, when UNICEF announced that an Indian child was more likely to be malnourished than a child in Ethiopia. Former PM Manmohan Singh called it a “national shame” that the spectacular GDP growth for a decade and a half had scarcely dented child malnutrition rates. To Dr Rajan Sankar, director of nutrition, Tata Trusts, it has been a “big implementation and targeting failure”. In 2004, the Supreme Court passed a historic verdict for expanding the anganwadi system of frontline workers under ICDS. “India has paid attention to quantity, but not so much to the quality of that system. This is where everything must happen,” says Dr Shankar.
In many ways, POSHAN Abhiyaan will be a “game-changer”, says Alok Kumar, member of NITI-Aayog, which played an instrumental role in adopting the scheme. For the first time, there are clear definitions and achievable targets, nutrition is not being equalled to food, there is multi-sectoral convergence of ministries led by the women and child development department, there is the idea of a people’s movement—jan andolan—to take it forward, and there is technology, to get real-time data to monitor and guide the initiative at the grassroots. “Without all this, the earlier interventions reached only 5 to 10 per cent of the people,” says Kumar.
Dig deeper, listen harder, look longer: a hundred audacious ideas are putting social change into action. Hundreds of nutrition warriors—anganwadi sevikas to Swasth Bharat preraks, community mobiliser didis to badlav didis—are spreading the good word, engaging people and creating change.
This graduate started working with Asha in Majawada village, Bhindr block of Udaipur, last year. The challenge was the low attendance of pregnant women in mother and child health nutrition programmes. Trained to conduct community meetings to spread awareness, she reached out to pregnant women and told them about the importance of ante-natal care. After three meetings, the results showed.
Across Maharashtra, hundreds of kirtankars are linking devotional abhangs to the importance of nutrition to the mother and child, and influencing family matriarchs, who otherwise ignore health advisories. India’s poorest and hungriest people, the rat-catching Musahars of Varanasi, are growing kitchen gardens in their backyards. Their diet of rice or roti with salt is now peppered with sponge gourd and squash, pumpkin and bitter gourd. Across Bihar and UP, government medical colleges are integrating maternal, infant and young child nutrition into the undergraduate curriculum. In villages across Chhattisgarh, lactating foster mothers, dharam dai, are feeding children, while bahu, saas and pati sammelan are decoding breastfeeding. In Kerala, healthy baby shows by paediatricians and medical students are encouraging mothers to breastfeed their children well. Women across Jharkhand are now cooking in iron vessels to combat anaemia.
In Rajasthan, villages, the sarpanches are rallying for the nutrition needs of their people, taking part in panchayat workshops and comparing notes with peer groups in other villages.
When Shashanka Ala joined as deputy commissioner of Lawngtlai—one of Mizoram’s remote districts bordering Bangladesh and Myanmar—she enrolled her one-year-old son in the nearest anganwadi. Though she was happy that he made new friends, she saw that he was coming home with take-home ration in small packets of mostly rice and dal. “My first intervention was to make sure that hot cooked meals were served in the anganwadi,” she says. Further enquiry revealed that most children in the area were undernourished. A new and lactating mother herself, and a strong advocate of exclusive breastfeeding, she linked it to the unavailability of fresh fruits and vegetables in the region and inadequate infrastructure to cook hot meals. After rounds of discussions with the stakeholders, community NGOs and church elders, ‘Kan Sikul, Kan Huan’ (my school, my farm) was designed, and armed with seeds, compost and gardening equipment, parents, teachers and children started producing their own vegetables. The pilot project proved so successful that it was launched in all the anganwadis and schools in the district.
Far away from Mizoram, tiny toddlers are having a romp in their community creche in Churgui village of Jharkhand. Designed by Ekjut, a non-profit founded by Dr Prasanta Kishore Tripathy and his wife Nirmala Nair, it’s a community partnership. The child-carers are chosen by the panchayat, and Ekjut ensures their training. Children get a safe and protected environment, safe drinking water, safety from household smoke, hand washing stations, four nourishing meals and learn hygiene—for eight hours every day. “We monitor their language, cognitive and physical growth,” says Tripathy. “Most importantly, we maintain a constant dialogue with women and the community through participatory meetings.”
Her regular house-to-house visits, counselling pregnant women and their families, have made the villagers aware of the importance of nutrition. She also organises rallies, meetings with teenage groups and awareness drives on health issues. Most of it is done through the Annaprashan programme, which provides clarity about the immunisation and the food expecting mothers should take to have healthy babies.
Over the past five years, the Ekjut team has been documenting their growth parameters. One file on each child, showing growth charts and graphs and progress from dangerous red zone, through yellow to a healthy green. The outcome has been startling—27 per cent reduction in wasting, 27 per cent in stunting and 40 per cent in underweight—drawing international accolades and coverage in prestigious medical journal, The Lancet. “It’s an exciting moment. The challenge is to do things in a way not attempted before,” says Tripathy.
Children play after a meal at their community creche in Churgui village of Jharkhand’s West Singhbhum district.
It’s playtime now. “Hijume, hijume (come, come),” invites Saraswati, 27, one of the child-carers. Children pretend to be butterflies, pampargo in the local Ho dialect. They, sing, dance, clap and laugh: “Dup pe pampargo, undem pe pampargo, tingur pe pampargo (sit, bend, stand, dance, wriggle like a butterfly).” The smell of food wafts from a thatched kitchen nearby, along with the clanking of stainless steel. The children jump in joy as they are lined up for hand-washing. They sit in a circle, wield spoons and dig into khichdi with boiled eggs. As they drift off to sleep under a massive mosquito net, nine-month-old Pardhan Gop’s mother turns up. It’s her time to breastfeed him. “They learn new things and eat nourishing food, while we are free to do our work,” she smiles. The sun fades beyond the conical Chari Buru hills of West Singhbhum, cow bells tinkle and children’s laughter ring out.
“The State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties,” says Article 47 of the Constitution of India. But after 72 years of Independence, freedom clearly means different things to different people. But the time has come for everyone to declare a new independence: freedom from malnutrition for all.