She is tall, skinny and dark-complexioned. She sports a tattoo of lines and dots on her forehead, as if displaying a hieroglyphic text. Her neck is laden with beaded jewellery and a thick, rusted iron chain while the ears are pierced at two spots. The white sari draped till her knees contrasts with green and red glass bangles. Premwati, a Baiga woman, is always dressed like this.

The 25-year-old holds her three-year-old daughter in hand. Around the kid’s neck and wrist is tied a multilayer chain of metal. This is to prevent sickness, says Premwati, though the child is unwell most of the time. She does not know her daughter suffers from severe malnutrition; she thinks her daughter is sick because she eats less and excretes more. Though the local accredited social health worker (ASHA) has advised her to take the child to a nutrition rehabilitation centre (NRC) of Bichhiya block in Mandla district of Madhya Pradesh, she has not. 

Premwati is from Bhanpur Kheda village – almost five km away from the NRC, a facility in the community hospital to take care of the children less than five years of age suffering with severe acute malnutrition (SAM). It admits both the mother and the child for 14 to 21 days.

“I have been admitted twice in the NRC with my other two kids who died a few days after the treatment. I have lost my two kids; I don’t want to lose my daughter,” says Premwati, who now has more faith in her traditional cures.

Her neighbour, Fagani, also a Baiga, has a severely malnourished three-year old son named Amit. She too is reluctant to take him to the NRC. She says if she gets admitted in a hospital then she would not be able to take care of her other kids. “Who will feed them or cook food?” asks Fagani, whose husband works as a labourer in Raipur.

In Bhanpur Kheda village almost every child is undernourished. Majority of the village population is the Baiga tribe. In July and August, the ASHA worker referred seven kids afflicted with SAM to the NRC. But only four families went ahead to get treatment in the centre. The plausible reasons for the reluctance of the remaining three families are strong traditional beliefs, past experiences and inadequate support from the family.

To gauge the extent of malnourishment in this block, I studied the health record maintained at the anganwadi by the auxiliary nurse midwife (ANM). The register showed that several kids around five years of age had their weight in the range of kg, which is almost six kg less than the standard. A four-year-old weighs 10 kg, almost five to six kg less than the standard. Those in the age bracket of two to three years weigh merely 8-9 kg. Many among them have become susceptible to SAM and have been asked to go to NRC. The situation is no different in the other two Baiga villages that I visited, Kharpariya and Gadiya.

It’s not only the Baiga tribals who face the SAM scare; the other tribe here – Gonds – also have children with symptoms of stunting and wasting. However, the Gond people are willing to take the sick child for treatment. 

Fortunately, on the whole over the last three years, more and more people are taking their children to the Bichhiya NRC (though the data does not distinguish the tribe). In 2013-14, 125 children were admitted including 14 of the high-risk category. The next year, the figure rose to 218 (51 in high risk). In 2016-17, there were 214 admissions, with 106 severely wasted and 82 in high risk.

At the same time, figures show the intensity of malnutrition thriving in tribal villages. Health experts blame it on a failure pay attention to the baby’s development and quality of life soon after birth. On the other hand, district hospital doctors say authorities down to the local health worker level are very much sensitive to the critical situation, as reflected in the full occupancy at the NRC. Dr Surinder Wadkade, a paediatrician in the Bichhiya community hospital, says, “Total bed occupancy is a good signal when it comes to infant mortality. Second, it also shows faith in the facility despite tribals’ strong inclination towards superstition and orthodox beliefs.”

At the NRC, a bunch of children, mostly about a year old, are sitting in the lap of their mothers who are feeding them a whitish-colour liquid from plastic tumblers. The liquid, called ‘formula diet’ or ‘special feed’, is a mixture prepared from full cream milk or skimmed milk powder, grinded sugar, oil, water and puffed rice powder. In technical language, the formula is called F-75 and F-100.

“F-75 is given in the initial phase of the treatment. It has calories and protein in such a quantity that it can be easily digested. Only after the child is accustomed to this feed, we switch to F-100 which has high percentage of calories and protein,” says Kaliya Marawi, a caretaker at the Bichhiya NRC.

The special formula is prepared on the World Health Organisation (WHO) guidelines and is given almost eight times a day. A 100 ml dose of F-75 mixture gives 75 kcal of energy and 1.1 gm of protein, while F-100 gives 100 kcal of energy and 2.9 gm of protein.

Meanwhile, older kids are eating khichdi in steel plates. They are also fed by their mothers. They too get a calculated quantity of formula diet, also iron folic acid syrup once a day.

Only after the child has finished eating does the mother get her food, which is prepared by the local self-help group. It is a full course meal containing dal, rice and chapatti. Mothers get proper three-course meals and iron-folic acid tablets. Those with infants are taught to breast-feed frequently.

They are allowed to go home only they show weight gain for three consecutive days, are able to consume adequate amount of nutritious food, any infections and other medical complications are resolved and immunization record is updated. Also, the mother is taught how to prepare appropriate food and to feed the child, how to administer prescribed medicines, iron and folic acid at home and what to do in case of diarrhoea, fever and respiratory infections.

As the NRC is only for severely stunted and wasted children, it does not serve a large portion of mild to moderately undernourished kids. There is no mechanism or initiative that could address the real beginning of malnutrition starting from infancy. A lot depends on the child healthcare practices the family adopts.

Real damage

The family plays a key role in countering malnutrition. Family members can help improve the child’s health; conversely, they can also contribute to its worsening. In the Baiga community, the primary care of the newborn starts with the midwife who delivers the baby. After cutting the umbilical cord, the baby is cleaned with lukewarm water. Within an hour after the birth, the mother starts breastfeeding the child. Of course, that tallies with what modern science says: starting the breastfeed within an hour is the best way to keep the newborn healthy.

Yet, the same child is very likely to suffer from malnourishment within months. Why?

Rupe Armu, the auxiliary nurse midwife of Indravan village, says, “The condition of the women has to be improved to tackle malnutrition in the village. Women toil hard in the field, leaving the baby at home to be looked after by elder siblings. The baby does not get enough feed from the mother as well as semi-solid food, which is a must for a child above six months. That is the beginning of malnutrition.”

Since women are the major workforce they tend to get more involved in agriculture work, collecting wood and selling it in the market and hardly takes notice of the newborn’s diet requirement. Matiya Bai, 34, takes pride in claiming that within five days of childbirth she took the infant along with her to collect wood and did her routine chores.

Even after six months a mother continues to take the infant along with her without taking additional food along. Till the first birthday, a Baiga child gets nutrition solely from mother’s milk – without any supplementary food. However, the child is typically fed only six to seven times a day and not eight to 12 times as the WHO recommends.

Usually, semi-solid food is introduced after six months. (The NFHS–IV data shows that 42.7 percent children age six to eight months receive solid, semi-solid food and breast milk. It is a bit worrying figure as it has gone down from 52.6 percent reported in 2005-06.) Doctors say that at a baby is born with a large store of iron, which continues to deplete with age and it is from the fifth month that the child requires nutrients from external sources other than mother’s milk. And if it is not given, the newborn develops deficiencies and gets more susceptible to diseases.

In the Baiga community, even after belatedly introducing solid food, mothers continue to breastfeed children till the age of five or six – or even longer, until another child is born. The practice might have benefitted the child if mothers were healthy, but they themselves are often severely anaemic and underweight.

More importantly, the growing child does not get cow or buffalo milk. “Even though we are sick we have to feed the kid. We don’t give cow or buffalo milk,” says Tiku Bai. Baby food, as supplement, could have helped, but Baigas can’t afford it, or haven’t heard of it.

As the food intake is less in the crucial growing years, the child develops energy deficiency. The family believes the baby is not hungry. Premwati, for example, thinks her daughter cannot eat food properly. (This is not a phenomenon limited to the Baigas: across the country, only 9.6 percent of children in the age group of six-23 months receive an adequate diet.) This is the critical juncture when interventions can make a difference. But effective interventions are missing at this stage. Only after the damage is done in three years does the child get nutritional support from the anganwadi.

Fragmented initiatives

The government programme called integrated child development services (ICDS) is aimed to look after health, nutrition and education of children between three to six years of age at anganwadis. The scheme’s implementation in the three Baiga villages leaves a lot to be desired. I found the anganwadis at Kharpariya and Gadiya villages closed most of the time. In Bhanpur Kheda the anganwadi was open but there were only four to five children.

That is because women don’t send their children to the anganwadi due to social factors like hierarchy or status differences between Gonds and Baigas, says Indira Marko, ANM, Kharpariya village. “Moreover, a few of them have started different religious practices; therefore they don’t want to eat with others. The social stigma is getting so strong that women even don’t come to collect take-home ration for the child,” she adds. Only two or three out of the 23 children registered here come to anganwadi (provided it is open).

Also, many children are not in the village for better part of the year, as they are with their parents who seasonally migrate to other states in search of livelihood. ANMs and ASHAs lack motivation to mobilise families to send children here.

The cabinet committee on economic affairs has approved the revision of cost norms for supplementary nutrition for ICDS. The government has decided to spend Rs 8 per day per beneficiary instead of Rs 6 while for severely malnourished Rs 12 instead of Rs 9.

Supplementary nutrition under the National Food Security Act, 2013 entitles a child in the age group of six months to six years to a free meal through the local anganwadi. Children within six months to three years get take-home ration (THR) having 500 kcal of energy and 12-15 gm of protein. But it is usually not available, and when available, children don’t like to eat it because it has a bland taste. Children aged three to six years get morning snacks and hot cooked meal with similar nutritional value.

All efforts to treat severe acute malnutrition in the later childhood are welcome but they will mean little if there is no effective intervention at earlier, crucial stages.

A key link in early redress of the ‘national shame’

Nutrition Rehabilitation Centres (NRC), launched by the health ministry in collaboration with UNICEF in 2005, are housed in government-run community and district hospitals and they cater to severely malnourished children.

Infrastructure
A typical NRC has bed strength of 10 or 20, a kitchen, feed demonstration space and attached toilets/bathrooms. NRC wards are painted with child-friendly pictures keeping in mind the emotional and psychosocial development of children. Children admitted here usually stay for 14-21 days. There are four follow-ups of the children discharged, at an interval of 15 days. The criterion for discharge of children is 15 percent weight gain of the admission weight (WHO recommendation 2009).

Treatment
The treatment of SAM takes place at three phases: stabilization, transition and rehabilitative.
Stabilisation Phase: Children with SAM without an adequate appetite and/or a major medical complication are stabilised in an in-patient facility. This phase usually lasts for one or two days. The feeding formula used in this phase is starter diet which promotes recovery of normal metabolic function and nutrition-electrolytic balance. Children are monitored for signs of overfeeding or over hydration.
Transition Phase: This is the subsequent part of the stabilization phase and usually lasts for two or three days. The transition phase is intended to ensure that the child is clinically stable and can tolerate an increased energy and protein intake.
Rehabilitation Phase: Once children with SAM have recovered their appetite and received treatment for medical complications they enter the rehabilitation phase. The aim is to promote rapid weight gain, stimulate emotional and physical development and prepare the child for normal feeding at home.

Tracing SAM
Undernutrition includes stunting (chronic malnutrition), wasting (acute malnutrition) and deficiencies of micronutrients (essential vitamins and minerals). It is an underlying factor in almost one-third to half of all children under five years who die each year of preventable causes. A relation exists between undernutrition and child mortality due to common childhood illnesses including diarrhoea, acute respiratory infections, malaria and measles. Three indicators, weight-for-age, height/length-for-age, weight-for-height/length, are used to identify three nutrition conditions: underweight, stunting and wasting, respectively.
Frontline community workers (ASHA, ANM and anganwadi worker) identify children with SAM by using simple coloured plastic strips that are designed to measure mid upper arm circumference (MUAC) and monthly measurement of weight. They should also be able to recognise nutritional oedema (swelling) of the feet, which is another sign of this condition.

Basic Facts
•    There are 966 NRCs in 25 states/UTs. It is estimated that around 93.4 lakhs children have SAM as per National Family Health Survey (NFHS)–4 and 10 percent of them with medical complications may require admission to NRC.
•    The total number of children enrolled at the NRCs in 2015-16 was 1.7 lakh.
•    Currently, there are 330 NRCs in Madhya Pradesh. In 2015-16, more than 79,000 children were admitted in NRC.

(Source: Operational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition and
government portals)

archana@governancenow.com

(The article appears in the November 30, 2017 issue)