The Shahabad malnutrition treatment centre, in Rajasthan’s southeastern district of Baran, may perhaps never have existed and little Satish Sahariya (name changed) would probably not have been alive today if the deaths of malnourished Sahariya children had not rung alarm bells in Jaipur’s corridors of power about a decade ago.

The social activism around those hunger deaths saw the first public interest litigation (PIL) being filed in 2001 in the supreme court by the People’s Union for Civil Liberties (PUCL), Rajasthan. Various civil society organisations also stepped in to address the crisis. There was, for instance, the Freedom from Hunger and Fear Campaign (FHFC), a unique intervention for the Sahariya community in the states of Madhya Pradesh and Rajasthan anchored by ActionAid, which had a strong focus on children.

Over time, such mobilisation put pressure on the authorities to act.

In 2008, the Rajasthan government took the major step of setting up malnutrition treatment centres (MTC) in its district hospitals, which offered treatment based on the guidelines set down by the World Health Organisation (WHO). According to those guidelines, a child’s height, weight and appetite were to be noted on admission, followed by the enforcement of a diet, drug and monitoring regime that could take two to three weeks to complete, depending on the child’s level of malnutrition.

As per plans, the progress was to be tabulated on a grid that outlined various parameters.

When two-year-old Satish was admitted, he weighed 6.4 kg – less than what a normal Indian baby of one year should have weighed. His distended abdomen, reddish hair and listless eyes indicated a very severe case of malnourishment. Two weeks after his admission, he had gained almost 1 kg. Although Satish is still less than what a one-year-old baby should ideally weigh, the doctor attending to him, Dr Sudhir Mishra, who is the block-level chief medical officer in Shahabad government hospital, is satisfied with his progress.

Severely malnourished children like Satish should gain weight slowly but steadily. According to WHO protocol, it is important that stabilisation in terms of nutritional intake sets in before a baby moves from the initial phase to the next. “A quick weight gain could put too much pressure on Satish’s heart, or have other negative consequences,” Dr Mishra explains.

But what were the reasons for Satish’s condition in the first place? According to Dr Mishra, it was a combination of several factors, including high anaemia levels in the mother, early withdrawal of breast milk, and frequent bouts of diarrhoea. “It is a cyclical process. A malnourished child who has diarrhoea loses valuable nutrients and becomes more susceptible to secondary infections that drain his or her body of essential nutrients,” he points out.

A study conducted by the National Institute of Nutrition, Hyderabad, in 2004 found that 72 percent of children of Sahariya tribals, categorised as a ‘particularly vulnerable tribal group’, were underweight. What was disturbing was that the parents of such children did not even perceive them as needing medical attention.

A recent paper in the Indian Journal of Public Health assessed the nutritional health of Sahariya women and children and noted that parents often considered their severely malnourished progeny as “normal” babies who were a bit thin – they had little idea their children were at death’s door. 

In fact, malnourished children live on borrowed time. Not only are they prone to conditions like rickets, stunted growth, and poor development of the brain, their low immunity levels make them susceptible to infections. With their kidneys performing below par, they are at constant risk of dehydration or over-hydration, and they are predisposed to developing heart conditions that could prove fatal.

But things have improved greatly over the last five years if one is to judge by the experiences of Dr Mishra and others at the Shahabad malnutrition treatment centre. “Earlier, we had to send our teams to the villages to bring such babies to these centres.  Perhaps because news of government programmes reaches the community through social activists, Now we see more people seeking treatment. This is a significant change,” Dr Mishra says. To cater to the increased inflow of patients, the centre expanded its facilities from six beds to 12. 

The room housing the malnutrition treatment centre (MTC) at Shahabad hospital, enlivened with bright pictures of Donald Duck, a very grey elephant and a bright green parrot, has other babies like Satish being attended to by their mothers. One young mother has a black eye. Her face a picture of sorrow, she does not even seem to register the cries of her emaciated baby. Asked how she got injured, the woman says she fell and hurt herself, though it seems like a case of domestic abuse.

According to the attendants at Shahabad MTC, only the mothers come and stay with the children, and most of them appear to be helpless. Alcoholism is very high among  Sahariyas and it is the women who bear the brunt of the drunken brutality of their husbands. Dr Mishra sees this as a challenge: “If both parents together took the responsibility of looking after their malnourished child, one could feel more confident about the prognosis. The problem is that usually it is only the mothers who come to the hospital and stay with their children.”

Disturbed family circumstances play their role in causing child malnutrition but nobody really talks about it. What worries Dr Mishra is that such factors also lead to the children being withdrawn prematurely from the facility. Every malnourished child needs at least two full weeks of in-situ attention to make adequate recovery. It is during this fortnight that their liquid intake is increased in a measured manner from F-75 (enriched formula milk) as a starter diet to F-100, as part of the “catch-up” diet.

Although the government provides an allowance of '200 every day to parents for out-of-pocket expenses, most families are in a hurry to leave – a trend noted not just at the Shahabad centre but elsewhere as well. “We have not been able to get a clear idea of why people want to leave so quickly. The child gets enriched milk and clearly stands to benefit from remaining here for the full period of treatment, but the relatives of the patient sometimes leave even by stealth. Whether this is because of the stigma associated with such treatment or because of economic factors like anxiety to rejoin work, we haven’t been able to fathom,” Dr Mishra says.

The early curtailment of treatment has negative repercussions on the efficacy of the protocol and doctors like Mishra are trying to address it by counselling families of the patients.

They would also like a more effective outreach system, says Dr Mishra. “We are serious about our malnutrition treatment centre and have asked for an ambulance, two nurses, one medical officer and a driver to be included as part of the team. With such a team we could greatly increase the number of beneficiary children and continue to reach those whom we have treated but who are presently all but lost to us because they live in remote locations and are difficult to access. We want to keep track of patients like Satish.”

With all his problems, Satish is actually a lucky baby. He has at least received treatment and now has a good chance of recovering from the ravages of malnutrition. There are hundreds like him growing up in tribal belt of Baran district who, not having benefited from medical attention, face an extremely uncertain future.

© Women’s Feature Service

The story appeared in the August 16-31, 2014 issue of the magazine.