Will Malnutrition Devour Our Children Forever?

Malnutrition has been plaguing India's children for decades, and even during the recent periods of 'shining' growth. The situation in Karnataka is very similar to the national picture. When the statistics are revealed through studies and surveys, or when starvation deaths among children are reported, there is much breast-beating and strident calls for action. Then, as surely as the uproar rises, it dies down. It is just the flavour of the moment and the government, the media and the public continue business as usual. 

True, some recommendations and actions do surface - court orders, mid-day meals, or a tweaking of the nutritional supplement provided through ICDS, but none of these lead to a sustained campaign against malnutrition among the age group that is most crucial for child all-round development, i.e., before the age of three years. Child malnutrition is a multi-dimensional and deep-rooted problem that no magic wand can cure with just a wave of the hand. It needs urgent action to stem the severity of near-starvation cases, on the one hand, by remedial actions through the ICDS, mid-day meals, the public health programmes, and PDS, and also sustained multi-pronged strategies to prevent malnutrition in the first place.

The scale of the problem is staggering. Two out of five children under three years in Karnataka are undernourished, as brought out by the National Family and Health Survey [NFHS] of 2007, only a little lower than the national average. Anaemia plagues over four out of five children and stunting, underweight and even wasting, the three main indicators of malnourishment, are startlingly high. Even more startling is the fact that some of these indicators have become worse in the last seven years. Babies with low birth weight [LBW] account for about a third of births in the country, so that they are off to a poor start. The main reason for LBW and early under-nutrition is the poor health and nutrition of the mother. Over half of all women are anaemic, and this proportion goes up during pregnancy, impacting on maternal mortality and the infant's health and nutritional start -up status. Traditionally, female children receive less nutritional attention than male children so that most adolescent girls are anaemic and under-nourished, thus beginning their reproductive life with a handicap.

The gestational period and the age group birth to three years are together crucial as over 90 % of a child's growth and development occurs during this time. Once past it, only some minimal improvements can be effected, especially during adolescence. Further, irreparable damage is done to not just the physical development, but also the various types of development of the child - cognitive, linguistic, motor and socio-emotional. Immune systems and resistance to diseases later in life are also affected.

These practical ill-effects of child malnutrition are being publicised periodically by surveys and studies, but such cries seem to be falling on deaf ears except when some major steps are taken by either activists or the media. Karnataka witnessed last year the results of a public outcry that led to a High Court judgement and subsequent Government actions that still are forthcoming only partially: Civil society activists and the media publicised some of the worst consequences of the neglect of the early signs of malnutrition in infants and young children in Raichur district in the north of the state in mid-year. A PIL followed, and in October, the High Court directed Government to take serious action to combat such malnutrition. Some remedial actions were taken in the affected areas and the Department of Women and Children [DWCD] set up the IMR and Malnutrition Committee to give comprehensive suggestions. The committee's rec ommendations, covering a wide range of preventive, relief-orienter and rehabilitative measures, wen submitted to the Court in early January.

The committee's recommendations range from urgent and shortterm actions to long-term and systemic ones and are multi-sectoral and multi-level in nature. While the Court's fmal orders were awaited, one expected Government to mount a fire-fighting type of campaign, with the help of the many NGOs that had offered it, to stem the rot of starvation deaths and nutritional deterioration. This did not happen on any large or sustained scale, yet the Department of Women and Child Development [DWCD] claimed that the numbers of children affected in many districts had dwindled enormously, while it was said to have increased and only in a few taluks. It is unclear how this rapid improvement was achieved!

In the midst of these events, a major corruption seam came to light. The continued NGO monitoring of actions taken by DWCD and Ministry of Health [MOH] in several parts of the state unearthed many anomalies in the type, procurement, distribution and preparation of the nutritional supplements for the children. The most glaring violation was that of Supreme Court's directive that ICDS should provide only locally prepared meals and supplements, prepared by women's groups. Karnataka had however contracted the preparation of ready-made mixes to Christy Friend Gram, whose factory is in Tamilnadu. Local communities often complained of stale smells, worms in the mixes, and bad taste. On the spot investigations did find these qualitative problems as well as expired packets, in additon to shortfalls in the supplied amounts.

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While the blame could be attached to staff at all levels, the most serious violations and siphoning off of allocated funds in connivance with the supplier were traced to the Director and Deputy Director of DWCD! They have been suspended, but civil society activists are demanding their dismissal. The contract with Christy was another target of activists, but the Dept. insisted it had to wait till March 31. After that date, the preparation was supposed to be decentralised to local Self-help groups [SHGs]. But, it is still being given as semi-prepared packets at taluk or sub-district levels to be mixed with water and finally cooked locally. The women's organisations that prepare the packaged mixes are trained and managed by Christy . This is again in contravention of the SC order that mandates fresh hot cooked meals and forbids the use of contractors.

As the court had asked Govt., it submitted an update after a few months. Once again, the Court found too little had been done and hence a special Monitoring Committee, headed by a judge and including some NGOs, was set up. Further action-oriented recommendations were made by this committee, the key one being that there should be action-oriented monthly health camps covering all children under six and pregnant women and lactating mothers, with the involvement of both DWCD and MOH. Pleading that this was not feasible, the Health Department got this order modified to once a quarter.
The first such camp was scheduled for July 15, and it did seem that the two departments had put forward a good action plan that included an awarchecks through home visits, with the culmination being the health camp at the health centres themselves. However, the plan did not cover women at all, and only took the weight measurement of the child, not the height; nor were any medical examinations conducted for children who were in the normal weight category.

Civil society activists monitoring these actions reported that in some places nothing had happened; in some others however it was done properly; in yet others indifferently well. On the whole, there was satisfaction that action had been taken at last, even if only partially!

Follow-up by on the long term recommendations of the IMR and Malnutrition Committee also needs to be taken up even while the urgent ones are being attended to. It is well-known that there is an intergenerational transfer of nutritional deficiencies from mother to child, to the adolescent girl and the cyclical process 'ltinues. Issues such as ill-health, poor hygiene and sanitation also impact on nutrition, so attention to all these are needed. The committee's recommendations need also to be discussed in wider fora along with other recommendtions by various groups/experts for possible applications in other states in the country.

Some immediate actions that are needed in the state as well as nationally:

• ICDS Coverage to increase from present 55 % to universalisation with priority to vulnerable groups of children;
• Provision of freshly cooked nutritious meals from locally available foods as far as possible with community groups as providers; and
• Establishment of as many Nutrition Rehabilitation Centres as needed in order to bring severely malnourished children back to normalcy [these may be attached to health facilities or to AWCs].

To ensure above three essential provisions that are as per Supreme Court orders of November 2001, the following are necessary: Increased budgetary allocations that are divided among the different age groups according to their needs as in some states;

• Regular growth monitoring of all under sixes, as well as assessment of health status as per norms;
• Identification of nutritional status of all children under six and remedial nutritional therapy for all malnourished children under six, especially for under threes, either in situ or in nutritional rehabilitation centres along with daily monitoring of their progress with corrective actions accordingly; the mother or other caregiver to be involved in this rehabilitation so that they understand how to prevent the child from sliding back into malnutrition after they go home;
• Continued monitoring of the nutritional and health status of all women in the reproductive age group and adolescent girls to detect deficiencies in their status and to take remedial and preventive actions;
• Regular home visits by ICDS and frontline health personnel such as the ASHAs and ANMs during a woman's pregnancy and the first year of an infant's birth to promote the woman's nutrition, correct breastfeeding and weaning practices, frequent feeds as appropriate for each young age group, and child stimulation, which is known to aid in both nutritional and allround development;
• Adequate training of field health and ICDS personnel for these tasks;
• Universal PDS that includes provision of local foodgrains and pulses in quantities commensurate with household food security;
• Involvement of the local community, which needs training too, in ICDS and nutritional therapy, by energising existing committees like the Anganwadi mothers' committee, the Water, Sanitation and Nutrition Committee, etc.;
• A joint monitoring team in each district and gram panchayat, with representation from the Govt., elected representatives, civil society and local community groups to monitor the progress and outcomes of the above steps, recommend remedial actions and provide feedback to higher levels.
• Full transparency and accountability, with severe penalties for the non-performing and/or corrupt officials.

In addition, a massive communication and sensitisation exercise on nutrition needs to be launched to inculcate good nutritional habits among the general population, especially young children, adolescent girls and women, and rid people of wrong beliefs and myths that lead to food taboos for pregnant and lac tating women and the new born. Several examples abound from other sectors such as the recent TV ads on NRHM, ASHAs, the Meena series on girls' edua has identified a tion and clean village in nutritional latrines, and special effo years in the Red Ribbon Express 0. Wast-AIDS. How sad that there are+l %. ally no such efforts to promote ffi5 trition which is the foundation for a healthy childhood that alone can fulfill one's full potential! Other avenues must also be sought, such as radio serials followed by discussion fora, street plays, jingles, posters that even an illiterate can understand [not wordy ones], etc.

Above all, what is needed is a "Free Children from Malnutrition" Mission, with adequate financial and human resources for it and the political will to see that it succeeds and is sustained. The time gap between our growing awareness of this issue and an urgent response is extremely worrisome. The Government must respond to this 'silent emergency' in a mission mode, and set monthly goals as part of this year's annual plan; while the five year plans must address the matter of sustained fulfillment of the basic health and nutrition requirements of children and women throughout India.

At the same time, we need to ask ourselves why most of our people are poor - is it because their remuneration is far less than what is needed for the basic living needs of a family, while the fruits of their labour are reaped by a few, or because their employment opportunities are increasingly blocked by our policies or a combination of the two? Unless the purchasing power of the family is vastly increased, along with heightening its understanding 'of what a child's and a woman's nutrition entails, its ability to follow even the minimum nutritional guidelines will be nil.
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The scourge of child malnutrition is not just a "National Shame" as our PM says, but a crime against our innocent children. It is also a gross violation of child rights and of our constitution that assures every individual the rights to life and health as fundamental rights. Unless each and everyone of us is burning with fire in our bellies, and join hands in demanding that we save our children from such a horrendous fate, and at the same time, take actions to ourselves remedy through practice and advocacy the apathetic attitudes towards child and women's malnutrition, the underweight, stunting and wasting figures in successive NFHS or other surveys will only fluctuate marginally, while generation after generation of children emerge, even if they survive, depleted of their energy, growth and overall development, into a caricature of an able-bodied and mentally alert adult.  
 
R.Padmini 
Trustee, Child Rights Trust, Bangalore