How do we fix India’s ‘stunted’ growth?
Despite having a food safety solution since 1975, our progress has been slower than some of the poorest countries in sub-Saharan Africa. How do we fix it?
Little Vaishnavi is two-and-a-half years old but she can hardly raise her head from her mother’s lap on her own. She looks at people from her big, round, kohled eyes and has a distended belly. Weighing a total of 5kg, Vaishnavi is suffering from severe acute malnutrition (SAM) and is currently lodged in the Nutrition Rehabilitation Centre (NRC) at the district hospital in Uttar Pradesh’s Pilibhit district. Her mother says that Vaishnavi never took to breastfeeding, so they gave her formula milk. Over time, her growth was affected by the absence of vital nutrients that are present in the mother’s milk. Stunting is a largely irreversible outcome of chronic malnutrition and repeated bouts of infection during the first 1000 days of a child’s life.
Ruth Sampson, a staff nurse who works at the NRC, says that most people who bring their kids to the centre are completely ignorant about the causes of malnutrition, even simple ones like breastfeeding children up to the age of six months. “Although there are some who belong to poor families and are not able to provide for their children, most of them are here because of a lack of awareness,” she remarks.
India has one of the highest rates of malnutrition in the world and SAM accounts for one-third of the total under-5 child deaths (12 lakh). According to the National Family Health Survey (NFHS) 4 data, the percentage of children under five who are stunted (too short for their age) has gone down from 48 percent in 2005-06 to 31 percent in urban and 41.2 percent in rural areas. However, malnutrition rates continue to remain high for many parts of the country. Also, more than half of the country’s population does not consume adequate vitamins and minerals, leading to a deficiency of micronutrients which is also called hidden hunger because it does not have visible manifestation. It is dangerous because despite not being visible, it can have detrimental effects on the overall health outcomes of the population. Dr Sheila C. Vir, who is a nutrition consultant and director of Public Health Nutrition and Development Centre, says, “The NFHS 4 data is encouraging but if you look at the average annual reduction, it is about 1.2 to 1.3 percent. Ideally, it should be almost double of that. So, we need to go faster.”
Rural face of malnutrition
In UP, which has one of the worst indicators for nutrition, a community engagement and leadership development pilot project has been launched in five districts (Pilibhit, Lakhimpur, Kannauj, Allahabad and Jhansi) by an advocacy group in order to mobilise and develop community leadership at the district, block and panchayat levels, and build their capacity to establish sustainable monitoring mechanisms for ensuring the greater reach and uptake of health services. Pilibhit district, with 52.6 percent children under five stunted, 21.6 percent wasted and 7.8 percent severely wasted, has been identified as one of the High-Priority Districts for the pilot project. The district’s villages observe Village Health Nutrition Day (VHND) three times every month: on the 5th, 15th and 25th. The day marks the convergence of the village Pradhan, the Anganwadi workers, Accredited Social Health Activists (ASHAs) and the Auxiliary Nurse and Midwife (ANM) at the nearest Anganwadi sub-centre where they take a stock of the nutrition status of children.
At the small Anganwadi sub-centre in Khananka village, weighing machines have been laid out in the verandah and children of all ages have been asked to line up near it. An ASHA worker is settled in a chair with a record book and a pen, asking older children to step on the machine and placing the younger ones on a flat weighing scale. Sarvesh, another ASHA worker present at the centre, says that the village had 14 children who were undernourished some time ago but the number has now gone down to six. The village does not have any severely malnourished kid. Sarvesh says that the improvement has come only because they have gone door to door raising awareness about the causes of malnutrition. “Even low-cost foods like seasonal vegetables found in the village and green leafy vegetables like spinach can be used daily to provide the much-needed nutrition to kids. We tell families that after your child is six months old, you can give them food that you cook at home, like the water in which you cook pulses. And that, along with breast milk, is enough.”
In Parsiya, because of the involvement of community leaders like the Pradhan, along with Anganwadi workers and ASHAs, the village does not have a single case of undernutrition. Pradhan Suman Mishra and her husband Dinesh, who is a retired Army personnel, used to live in Pilibhit before the former was elected the village Pradhan. They shifted base to the village in order to be available to villagers whenever need be. The village Pradhan rues the fact that because of staying in the village, her working hours are fluid. “People from the neighbourhood can drop in at any time to discuss a problem that they are facing,” she adds. After Suman took over, punctuality was an issue with ASHAs and ANMs in the village. However, through their painstaking efforts, they were able to motivate the community-level health workers to show up on time and be more involved in creating awareness on malnutrition.
The district is equipped with two well-maintained NRCs—one in Bisalpur block and another in Pilibhit district hospital—where children who are severely malnourished are provided rehabilitation. The NRC has 10 beds but the number of children pouring in to seek treatment is higher at any time of the year, says Sampson. “The numbers swell even more during monsoons because children who are malnourished are more susceptible to develop infections like diarrhoea,” the staff nurse adds. The kitchen, where food is cooked for the kids who have been referred to the NRC, is clean and well-kept. Sampson says that she has seen several kids being admitted to the centre with life-threatening illnesses and then being discharged in a healthy condition, but some of them come back with all the progress made at the NRC reversed.
According to Dr Vir, “The readmission rate in NRCs is very high. This problem has a social dimension to it as well. Although there is no data to back this claim, I have observed that often children who are severely malnourished come from families where domestic violence is prevalent or that have ailing mothers. When they go back to the same environment, they go back to square one.” Eradicating malnutrition also means empowering women and creating an environment that enables children to have a mentally and physically healthy life.
The urban face of malnutrition
Arvind Singh, who is associated with an NGO named Matri Sudha that has been working in the field of nutrition and education, says, “Most people in urban slums work as labourers in the unorganised sector. So, that brings in a certain amount of financial insecurity. You never know when you will be out of work and when that happens, it affects their food habits as well.” However, he adds that there is also a section of people who can provide for their children but are careless and let their children consume junk food.
Dr Vir remarks that the problem of creating awareness can be tackled easily by using the existing channels. “The government does not have a single public health nutrition expert at a senior position in any department. Therefore, understanding of the problems related to nutrition is not there,” notes Dr Vir. However, she adds that India has all its policies in place and they can be used to create awareness about the issue. For example, ingestion of faecal matter is another underlying cause of malnutrition, especially in rural areas where people defecate in the open and animal faeces are lying all around. It affects the internal lining of the intestine and that prevents the body from absorbing nutrients, causing stunting and possibly anaemia. The public health nutritionist says that if we start creating awareness about the importance of washing hands before eating and cooking or feeding children under Swachcha Bharat Mission (which is a high-priority programme), then we will be able to achieve the much-needed level of environmental sanitation without investing into it separately.
Singh says that a lot of the children in slums also go unnoticed until the time they are severely undernourished as there is a paucity of relevant data. At the time he started working with malnourished children in Delhi, the social worker was aghast at the lack of data on the basis of which one could ascertain the gravity of the status of malnutrition in any slum. “We did a survey in Nardan Basti and were surprised to find that a lot of the kids in that locality were undernourished. When we matched our data with that of the Anganwadi centre, we found that there was a huge mismatch,” says Singh. It was then that they started strengthening Anganwadi workers by providing them adequate training and apprising the government of Delhi of the situation on the ground.
When it comes to malnutrition, there is a tendency to link the condition to low economic status. It is considered a problem that afflicts the poor, however, NFHS 4 data shows that high malnutrition rates are prevalent in high wealth index as well. Dr Vir says that it should be a matter of grave concern for policymakers because people in these categories are not covered under Integrated Child Development Services (ICDS) or fall within the reach of a strong primary healthcare centre. “We need to reach out to them through other channels like private schools and workplaces or private health practitioners. These are areas that we have not yet tapped into,” she notes.
How do we get there?
The doctor in-charge of the Community Health Centre (CHC) in Pilibhit does not mince words when it comes to the dismal status of nutrition indicators in Uttar Pradesh. “India doesn’t want to spend on health outcomes. And people don’t plan their health expenditures either. They’ll save money for educating their kids or getting them married, but not for any health emergency. Therefore whenever there is a health-related problem, it turns into a crisis,” notes Dr Thakur Das Gangwar. He adds that families bring their malnourished kids to the healthcare centre only when they become critical, before that stage they prefer going for low-cost solutions.
Since Anganwadi workers and ASHAs are the footsoldiers in the fight against malnutrition, the importance of having an adequately trained workforce cannot be emphasised enough. However, in the absence of a monitoring mechanism that works efficiently, there is no way to judge if this group is efficient and if they are not, how should the government deal with them. Dr Gangwar remarks that 30 percent of this workforce is not trained to tackle the numerous health challenges that the government expects them to manage. “We expect ASHA workers to counsel patients, parents to vaccinate their children and raise awareness about the importance of nutritious food. She cannot do all that because she is not adequately educated/trained to perform those duties. And they are never paid more than 2,000 to 3,000 rupees,” he notes.
Hirakali, who is an Anganwadi worker in Parsiya village says that her working hours are long and she has to show up for work on all festivals of the year—at the paltry sum of Rs 3,000 a month. Sometimes, she also spends out of her own pocket to take severely malnourished children to the nearest CHC. There are other Anganwadi workers who do not pursue their jobs with as much passion as Hirakali because the compensation is disappointing.
Dr Gangwar says that a lot of undernourished children go unnoticed because sometimes when a kid falls short of the WHO standard weight for their age by 200 or 300 gramme, the Anganwadi workers do not register them as undernourished because that would mean added work. “They will have to monitor the child regularly and give them supplements and poshahar (nutritious food). Instead, they just drop them from the list. They become visible only when the nutrition level goes down to a critical level,” he adds. Singh, who works with Matri Sudha in Delhi, agrees that the problem leads to botched data on the ground level. “A lot of them (Anganwadi workers) don’t know how to monitor growth or maintain records. There are separate charts to maintain records for boys and girls. But they often mix up the two. So, that data cannot be relied upon,” the social worker says.
Dr Vir says that the way media portrays malnutrition needs to change as well. She has a problem with the way the media shows a malnourished child as an emaciated, hungry-looking kid with brittle hair (those suffering from SAM). While severely undernourished kids get all the focus from the health ministry and the media (rightly so), the problem of stunting has become a kind of silent health emergency. Stunting is defined as the percentage of children, aged 0 to 59 months, whose height for age is below the WHO Child Growth Standards. It is irreversible in the first two years of a child’s life. “According to the NFHS 4 data, out of 10 children, four are stunted. But there will be pockets and communities where out of 10, seven or eight children will be stunted. When that happens, the society doesn’t look at those seven-eight children as suffering from chronic undernutrition. They become part of the entire community and they get lost with our policymakers and politicians because they don’t look visibly malnourished,” rues Dr Vir.
Despite having the policy to tackle malnutrition since 1975, our progress has been slower than some of the poorest countries in sub-Saharan Africa. Dr Vir thinks that at the heart of the problem is the fact that the Ministry of Women and Child Development is responsible for preventive care (through ICDS which is a low-profile scheme), whereas the health ministry is responsible for curative care. “If the government merges ICDS with the health ministry and sets up a separate nutrition mission, the progress will be faster. To make a difference, we need to close the gap between missed opportunities and intervention.” For us to attain the sustainable development goal of ending malnutrition in all forms by 2030, the intervening period will have to see substantial progress on the ground. Better nutrition levels mean that we will have healthy, well-fed children who will grow up to be more productive individuals. Also, this is the UN decade for nutrition and fighting malnutrition is a goal that is being pursued by countries across the world. Therefore, India improving its nutrition indicators would give it the ability to have a greater say in matters of global health policy. The 2015 Copenhagen Consensus says that in India, every dollar spent on nutrition in the first 1,000 days of a child’s life can save up to $134. By pouring more money into the starving health sector, we would move towards winning the war against malnutrition. However, with the current number of stunted and underweight children, our leaders need to make the political choice to win the battle first.