Malnutrition - over and under

While the correct definition of malnutrition is insufficient, excessive, or imbalanced consumption of nutrients, in this blog I almost always refer to the under-nutrition of malnutrition. I'm admittedly only covering one side of the issue, even though over-nutrition, obesity, is a huge and growing (pun intended) problem around the world. All malnutrition is dangerous to health and can lead to serious short-term and long-tem problems.

In India while under-nutrition affects the most people, over-nutrition is of serious concern as well, almost exclusively affecting upper classes.

A new study has been released today in which data from approximately 40,000 men and 60,000 women in Mumbai was analyzed and it was determined that nearly 1 in every 5 men and women were underweight at the same time that another 1 and 5 men and 30% of women were overweight. Thinness was associated with low levels of education while heaviness was associated with higher levels of education. Here's a link to the study: http://www.id21.org/health/h3hs2g1.html

Here are some more statistics from the National Family Household Survey III which I found illuminating on the malnutrition status of Indians:

• -Nationally, 45% of children under three are stunted, 40% are underweight, and 23% are wasted
• 79% of children in India are anemic - risk for anemia is almost the same for wealthy and poor households
• only 28% of children received any services at anganwadi centers in the past year (even though coverage is reported at 62%)
• 33% of women and 24% of men are vegetarians
• the highest prevalence state for obesity in women is Punjab followed by Delhi and Kerala - obesity is on the rise in wealthly women and Sikh women
• 41% of women in rural areas are underweight and 25% of women in urban areas are underweight
• 7% of women in rural areas are overweight and 24% of women in urban areas are underweight
• the more education a woman has, the more likely she is to be obese - 7% of women with no education are obese, compared to 24% of women with more than 12 years of education. same goes for wealth

These figures prove that across India, rich or poor, urban or rural, men or women, malnutrition (over and under) is one of the most serious health problems in the country and one that is being under-addressed.

Malnutrition Exaggerated

http://www.hindu.com/2009/11/28/stories/2009112857052000.htm

An article recently came out in the Hindu which claims that 25 children died from malnutrition in the month of October in just two villages in the Meghnagar district of MP. The deaths are attributed to malaria, anemia, and malnutrition.

The article then goes on to site malnutrition figures from around the state, but gives no clear evidence or authority for the deaths in Jhabua. The author is accusatory of government officials being complacent and the anganwadi system failing.

While I'm usual right on board with many of these criticisms and believe that journalist have an important role in highlighting situations like this, unfortunately I have to say that this article is wrong, and irresponsible journalism.

Meghnagar is our main district in Jhabua. We have health workers and a wide network of contacts throughout the district. When a child has SAM we usually know, when a child dies, we almost always hear. So far in the past month we've recorded 4 children dying from malnutrition. This is a number that has been confirmed by the Joint Director of Health for the area. I consider even 4 children's deaths due to malnutrition alarming. This should be enough to make newspaper headlines and to pressure government officials and social organizations to act.

But creating a panic and over-reporting the problem can cause a negative backlash. More time gets spent investigating and proving the allegations wrong then actually fixing the root of the problem.

We'll try our best over the next few days to further look into these claims to ensure that, God-willing, this article has exaggerated the situation.

New "Community Kitchen" scheme launched in MP

http://www.thaindian.com/newsportal/politics/scheme-to-tackle-malnutrition-launched-in-madhya-pradesh_100269553.html

Today we went to visit the anganwadi center in Umri, a town close to Jhabua's district center but rife with malnutrition. When I asked the anganwadi the standard question about the supplements she was providing to the children, she led me around to the back of the school adjacent to the center to a smoke-filled kitchen. The room was so poorly ventilated that I couldn't see without squinting and couldn't stand in the room without holding my breath, but through red eyes, I was able to see a delicious looking pot of dal and fresh rotis being cooked on a skillet.

The three women who braved these kitchen conditions were part of a newly formed local self-help group (SHG) who are now in charge of making the meals for the anganwadi center and the elementary school next door.

This is part of the Chief Minister's new solution for malnutrition, Sanjha Chulha, creating community kitchens to prepare full, hot meals as midday meals and anganwadi supplements instead of pre-packaged foods.

First week on, things seem to be going pretty well. The former system, which relied on many centrally located self-help groups to prepare ready-made food, was problematic and rife with corruption. I often saw wheat meant for schools on sale at the market. Common were stories of SHGs who made substandard food and profited from their economy. Anganwadis, who are already overburdened with responsibilities in health, nutrition, and education, spent large portions of their days cooking. There is plenty room for corruption in this model as well, but at least there will be more visibility and accountability will be placed with the community. While communities aren't always the best monitors or good at demanding the services they deserve, they're more reliable than a hand full of government inspectors and monitors. This will also provide a small income to women in the community (many mothers of small children themselves) and will foster greater community involvement in the centers.

While I don't agree that this program is revolutionary, nor will it greatly affect the incidence of severe acute malnutrition (those kids aren't going to the anganwadi centers), this is certainly a great concept and an improvement to the system.

Talk at Columbia University Tuesday October 20th

If you're in the New York area, please come by and listen to my talk tomorrow, Tuesday October 20th at Columbia University:

Title: Childhood Malnutrition in India- on the ground and on the horizon in Madhya Pradesh

Speaker: Caitlin McQuilling, Program Director the Real Medicine Foundation's Malnutrition Eradication Initiative in Madhya Pradesh, India.

Time: 1:00pm to 2:00pm, Tuesday, 20th October, 2009

Venue: 306 Russell Hall, 3rd Floor Library, Teachers College, Columbia University

Organizer: Development in South Asia (DISHA)

India is currently facing its worst drought in 37 years, a drought that is just beginning to have its detrimental effects on those living in rural areas across the country. While the national average for malnutrition in children under 5 is 47%, the rate gets as high as 90% in tribal pockets in MP. Malnutrition has been a chronic problem for years but is now only exacerbated by drought and economic depression. I'd like to talk about the stark ground realities, but also offer some solutions and examples of actions that groups like ours can take and how individuals, even in the US, can help out.

Not just too little too late

Its pouring right now in Jhabua, but even though farmers here have spent the last 4 months praying for more rain, no one is rejoicing right now.

The monsoon and growing season ended in Jhabua last week after a disappointing season - the most disappointing in 37 years. Across India rainfall was 23% below average, with deficiency climbing as high as 36% throughout areas in the Northwest. Just type in "India drought" into a Google News search and you'll find 100s of articles on the subject and analysis on the dreary consequences some experts predict.

This year's crop is expected to be at least 50% deficient. Farmers here have spent the past week or so harvesting their crop, drying goods and storing them for the season or sale in the market. Now there is a danger that many of the crops I saw today laying in bushels in fields or in trees to dry will get wet and mold, ruining what little the farmers have left of their months of work.

These poor farmers cannot get a break.

On migration

Last night as I got off the Rajkot Express train from Bhopal to Meghnagar, Jhabua I stepped onto a full platform – at 3am.

Families lay strewn across the platform, huddled together with a few possessions, using thin sheets as a blankets or laying bare across the dirty train platform. Children, many babies too young for a journey like this, most too undernourished, slept peacefully on their backs. A few men and women were sitting up and stared at me with a weariness in their eyes so heavy, they couldn’t even muster up surprise to see a blonde tiptoeing around them. Maybe they were unable to sleep because they were anxious about the road ahead or maybe they were aching from the concrete on which they were trying to rest between their long journey from the village to the train station and the train coming in at 5am to take them to their worksites the next state over. Even though I’m usually not one to be shy with a camera, I’ve never mustered up the courage to take a picture of these migrants – I feel like I am intruding on the most vulnerable part of their life cycle.

These wretched masses and ghostly figures have been a fixture of my late night travels between Jhabua and Bhopal (the Meghnagar Bhopal train leaves at 12:30am; the Bhopal Meghnagar train arrives at 2:30am; the train to Gujarat leaves at 5am). Their nightly migration vigil highlights the challenges I’ve faced during the day. Migration is a monumental challenge for public health, education, and development, one that colleagues and I wrestle with everyday.

An average of 64% of Jhabua and Alirajpur’s population migrates seasonally to neighboring states Gujarat, Maharashtra, or Rajasthan or to Indore (see map xx). There are two types of migration patterns in Jhabua and Alirajpur, the seasonal migration of the poorest of the poor out of necessity and the migration of the moderate poor who leave for better economic opportunities. The better off of the migrants are predominantly men who leave their families behind and may come back home at more regular intervals. The poorest of the poor bring their entire families, malnourished children and all.

Migrants leave Jhabua and Alirajpur every year around the end of the harvest time in late September – November and come back around planting time in May/June. Some migrants may come back for festivals such as Diwali or Holi, but many do not come back for another 6 months.

Migration is one of the, if on the, greatest challenges for any malnutrition work. Any progress we’ve made in a child’s weight gain is often lost while the family is migrating. Training migrants have received on the use of local foods to prevent malnutrition doesn’t often apply in their new locations. Functioning self-help groups break down. Its hell for our follow up and monitoring and evaluation systems.

A family may know how to use locally available foods to make nutritious meals and may have home remedies for diarrhea and other illnesses from locally available materials, but this knowledge often is useless in the places they migrate too. Anyone who has traveled through India can see that landscape, people, food, culture, and language can differ vastly from state to state, region to region, and even district to district. What is known to be nutritious in one location may not be available or may be prohibitively costly in another location. Migrants do not mix in with the inhabitants of their adopted communities. They often live in small camps or on construction sites together, quite separate from the larger community. There is discrimination towards migrant laborer from local residents (this is a worldwide phenomenon isn’t it?). With this separateness, cultural and sometimes legal, most migrants do not reach any of the social and health services in the states where they migrate.

When our migrants leave Jhabua, they may make double the wages (many make from 150-200 inr a day in Gujarat), but food costs more and health facilities are inaccessible. Bhils who often only speak a little Hindi, find themselves in a foreign land in Gujarat, Maharashtra, and Rajasthan, with different people, different languages, different foods. In countless conversations I’ve had with migrants in Jhabua and Alirajpur, I’ve only heard from a handful of migrants who received any type of medical care while in Gujarat. No preventative care. Our HIV/AIDS program faces a constant uphill battle to try and get HIV+ migrants transferred to ART centers in neighboring states during migration so they can continue receiving their medications every month (I’ll write another post on the challenges of HIV and migration).

Migrants often are employed in agriculture or construction, which means long days, backbreaking labor, and children left to themselves. Mothers can’t take time off of carrying bricks on their heads to breastfeed every two hours, let alone cook a nutritious meal for the children. During construction, children often subsist on white bread and biscuits during the day, with one home cooked meal at night. Biscuits and breads fill the stomach, but offer no nutritional value and cost more than a nutritious dal and roti.

With this year's drought (the worst in 37 years), our contacts throughout the field in Jhabua, Alirajpur, and Gujarat estimate that migration is about 10-20% more from Jhabua this year (sources include railway station masters and labor contractors). However in the Bundelkund region of Northeast Madhya Pradesh, where the drought has been even more harsh this year, we are getting reports from colleagues that this year’s migration is the highest they’ve ever seen, with each bus leaving the region packed to the brim with people leaving with all their belongings – this year many have no plans of coming back. From Bundelkund they’re all headed to Delhi – where they are likely to find no welcome reception with the Delhi City Planning Commission actively clearing migrants’ slums in preparation for the Commonwealth Games next year.

There are many challenges we face in migration, but with those challenges, interesting opportunities for cross-state collaboration with partners and government, interdisciplinary problem solving, and flexible approaches. Mobile crèches for the children of road construction workers, teachers who travel with migrating labor, HIV target interventions for migrants – there are numerous groups doing exciting things to reach out to one of the most vulnerable groups in the country. Throughout the next few months, I’ll try to bring out some of these various approaches to the problem in this blog as I explore how to tackle migration and malnutrition for our program.

Petlwad NRC - Turning away patients

Wednesday I wrote about how Jhabua's NRC is 15 patients beyond capacity and Thandla's is 10 above. Today I visited the third NRC in Jhabua, Petlwad NRC which is a 10 bedded facility and one that will only accomodate 10 patients. Not one over. While the other NRCs in Jhabua make room for the extra patients, Petlwad's NRC is turning them away with promises for admission the next admission cycle.


Now, Petlwad NRC staff are not heartless and have their own constraints. The staff are following the directions from their superiors (not everyone is as headstrong as my friend Heena at the Jhabua NRC). They were convinced they would get in trouble for admitting a child over capacity or off cycle. This block level hospital is not as well equipped and does not have as much extra space as Jhabua's district hospital. The NRC is a small building tucked in the back of the hospital campus. Theres no room for spillover patients in the hospital's pediatric ward or other wards. There doesn't seem to be strong committment from hospital in-charges (whom I've interacted with before).

I understand all these limitations, but regardless, this is not right. This NRC "waiting list" has disasterous consquences. A patient should never be turned away from treatment.

I have experienced multiple times the incredible challenge that all health workers face in the field of trying to convince a mother to take her child to an NRC. These centers are sometimes hours away in a non-familiar setting, often a district hospital where tribals are often treated poorly. They have to spend 14 days at this center while missing out on key responsibilities at home. While they receive 65 inr a day in wage compensation, this often does not make up for the farming work they are missing, or tending to their livestock, or feeding their other children or their demanding husband. "What, I'll go to the NRC with this child and the other children will become malnourished," one mother told me.

I've failed many times to convince a mother to go to the NRC. And I don't blaim those mothers. I wouldn't want to spend 14 days at an NRC, even the best ones I've seen.

So despite all odds and challenges, if we finally get a mother to agree to bring her child to an NRC and they gets turned away from treatment. We've lost her and quite possibly her child.

This is why we need village based treatment for uncomplicated cases of severe acute malnutrition. While I didn't see the children turned away, I'm sure they weren't extremely complicated cases on the verge of death (I really hope not, the Petlwad staff assured me a complicated case would be referred to Indore). These children who were turned away would be perfect candidates for Ready to Use Therapeutic Food (RUTF) - a supplement medically and nutritionally equivelant to the one given at NRCs, but without the risks of contamination associated with milk/water based products (see September 16th post for a detailed explanation of RUTF). This take-home treatment, however, is not approved for use in India because of politics.

What do we do?

While we're sorting out the RUTF issue, we have to make NRCs work and add more since even when RUTF is introduced, we'll still need functioning NRCs for complicated SAM cases. To start with in the Petlwad case, they do have 4 staff members for 10 patients. There must be a way for them to accomodate more patients. With a little pressure from the community, maybe the in-charge will sacrifice his big office? Maybe the hospital staff could sacrifice their breakroom? I'm no expert in hospital administration, but surely they could find away. I'll be raising this in Bhopal.

The Science of Hunger

http://www.livescience.com/health/090916-hunger-defined.html

This article is a great intro to malnutrition and what it does to the body. Highlights:

"Every six seconds a child dies because of hunger and related causes"

"Under-nourishment occurs when people don't take in enough calories to provide them with the energy just to meet their minimum physiological needs. Malnutrition is more of a measure of what people eat, versus how much. Malnourishment occurs when people don't get the levels of protein, micronutrients (such as vitamins) or other critical components in their food, according to the WFP.

Malnutrition can have serious effects on the body:

• Chronic malnutrition can stunt the growth of children.
• It can also cause children to be underweight for their age.
• An acute case can cause wasting, or severe weight loss.
• It can cause deficiency in key vitamins and minerals, such as anemia, or iron deficiency.
• The weight problems and deficiencies can increase susceptibility to disease.
• Malnutrition can become a secondary issue when the body can't take up the nutrients in food because of diarrhea or other illnesses.

Deficiencies in vitamins and minerals exact their own toll on the human body:
Iron deficiency, the most common form of malnutrition, affects billions worldwide. It can impede brain development.

• Vitamin A deficiency affects 140 million pre-school children in 118 countries. It is the leading cause of child blindness and can make people more susceptible to diseases. It kills one million infants a year, according to UNICEF.
• Iodine deficiency affects 780 million people worldwide. Babies born to iodine-deficient mothers can have mental impairments.
• Zinc deficiency results in about 800,000 child deaths a year. It weakens the immune systems of young children. "

RUTF and its absence

Today was an eventful day for treatment....and lack thereof

Today MSF announced the quality assurance certification of Compact's Ready to Use Therapeutic Food (RUTF) in India. This means that after months of quality and safety tests and inspections Compact's eeZeePaste can be safely used for the treatment of uncomplicated severe acute malnutrition (together with UNICEF, MSF is the recognized world authority on RUTF QA Certification). No word yet from the government on whether or not this life saving treatment for severe acute malnutrition will be allowed for use domestically.

I also visited the Nutrition Rehabilitation Center in Jhabua where they are treating 35 children with severe acute malnutrition (SAM) - 15 patients over their capacity of 20 beds. Patients are flowing into the pediatric ward of the hospital which is also over capacity with plenty more children hospitalized for severe diarrhea and cases of typhoid with 2-3 children per bed. Neighboring Thandla's NRC is also over capacity with 25 patients in their 10 beds.




As I sat down to catch up with Heena, the amazing nutritionist at the NRC who works above and beyond the call of duty, a batch of 5 children came into the NRC from just one block. She had been told the previous week not to accept more children than the NRC's capacity, but put her foot down saying that she would not send a child with complicated malnutrition home to die in the village. And she hasn't. As I shadowed her and the attending pediatrician through the process of screening and admitting these children, one child, a one year old with a shriveled up face and the leathery, wrinkly, hands of an old person started having trouble breathing. As the doctors rushed this child into the critical care unit with oxygen and started to insert a nasal gastric tube, I had to look away and sat with the other patients. Four children sat in worried mothers' arms, their dull-eyes almost waiting to be next. It's heartbreaking to see a child without that spark in their eye. As a one or two year old, what is exciting about the world if you don't even have the energy to lift your head?

The children I saw today desperately needed inpatient care for their severe severe severe acute and complicated malnutrition. But they didn't have to get to this point. They could have, should have had access to clean, safe, medically sound treatment for their severe acute malnutrition before they developed complications and began to slip. Also there should have been an intervention with these children when they had moderate acute malnutrition so that they wouldn't have become severe and needing treatment. Families should have been counseled and should have had access to prevention services so that these children wouldn't have become malnourished in the first place.

But the biggest tragedy today is the fact that these children desperetely required treatment at the village level to prevent the state they presented with at the NRC. And that treatment is available. But because of politics, field level workers are not allowed to use this treatment.

I'm opening up a can of worms for arguing on behalf of RUTF, but this is life or death. Politicians do not stare into the dull eyes of a malnourished child.

There has been a lot of debate about RUTF in this country since the Department of Women and Child Development (not the Department of Health) asked UNICEF to stop using RUTF in their emergency treatment efforts for severely malnourished children in the flood zones of Bihar and in Kalwa Block of Khandwa, MP (where over 60 children died of malnutrition in just 3 months). UNICEF was severely reprimanded for using an RUTF imported from France without explicit national government permission. For more press coverage of this debate, see the following articles:
http://in.reuters.com/article/domesticNews/idINDEL49936320090804?pageNumber=1&virtualBrandChannel=0
http://www.timesonline.co.uk/tol/news/world/asia/article6739362.ece

Opponents of RUTF cite the high cost of RUTF and question its sustainability. They fear that RUTF will be used as a supplement and will slowly begin to replace breast milk and rice and dal in the family pot. They do not understand that RUTF is a medical treatment advised for 14 days and cannot be replaced with local concoctions. Opponents of RUTF do not understand RUTF.

Let me clear up some facts about RUTF.

As I've described before, there are currently an estimated 8 million children under five years of age across India with severe acute malnutrition (SAM) a condition defined by extremely low weight-for-height or mid-upper arm circumference and carrying the risk of death for 10-20% of those afflicted. All these children require urgent treatment to bring them back to normal growth, but not all of them require hospitalization. Approximately 80% of these children, or 6.4 million, will have uncomplicated SAM, which means that while they are dangerously malnourished, they do not present with any complications such as pneumonia, hypothermia, edema, diarrhea etc. These uncomplicated cases require urgent care not necessarily in a facility but can receive RUTF administered in a community-based therapeutic care model. There will never be enough facilities in MP to treat the 1.3 million children who require SAM treatment right now.

There is currently no treatment option available for out-patient care for severe acute malnutrition in India. While there are many local recipes available for community based treatment of moderate acute malnutrition, these “home remedies” cannot be used for severe acute malnutrition because of the SAM child’s delicate state. A child with SAM needs specialized treatment that properly balances carbohydrates, lipids, proteins, and micronutrients in an energy-dense formula. Because of their fragile state of malnutrition, potential contaminants in this treatment, whether from unclean water or any other toxins that can be found in many village kitchens, may put the life of a child at risk. RUTF provides the right dose of nutrients to help a child with SAM recover quickly, without chance of contamination

RUTF is a medicine, not a supplement: RUTF is a formulation that should be treated like a medicine. It’s the equivalent to the F-100 formula (milk-based) used at hospitals across India but is instead made in a paste that can be safely given to a child to take home. RUTF is not a supplementary food or a method to prevent malnutrition, but is a treatment for a fixed amount of time to get a child back on a normal growth pattern and prevent death. RUTF has had astounding success in malnutrition treatment programs around the world.

The advantages of RUTF are:

a) if the child passes an appetite test, uncomplicated cases of acute malnutrition can be managed without going to the hospital
b) no risk of contamination since the product does not require water
c) no special training is needed to use RUTF
d) highly cost-effective compared to in-patient based approaches
e) weight gain from RUTF is higher than weight gain from F100 (5 times) and from fortified flours and other fortified foods used in supplementary feeding programs because the energy-density of RUTF is higher than in other formulations.

RUTF gives the mothers/families, assisted by trained local health workers, the primary role in treating malnutrition in their children. In this way, thousands of malnourished children can be managed in the community without caregivers having to spend days in hospitals and away from their families and work. It takes much of the burden off of government nutrition rehabilitation centers, allowing doctors to focus on only the most serious, complicated cases of SAM.

RUTF should be administered weekly under the supervision of trained health workers in conjunction with the child’s family over a 6-8 week period.

RUTF will be administered until the child has gained adequate weight. The child will then transition to a nutritious diet prepared by their family using locally available products along with micronutrient supplements.

RUTF is equal to F100/F75 not to local supplements: The WHO recommendations state that F100/F75 should ideally be used for inpatient treatment of complicated SAM cases. While the Government of India, with the recommendation of the Indian Academy of Pediatrics, recommends the use of F100/F75 - the same recipe, with equivalent nutrient content and higher caloric density used as a take-home formulation has raised an incredible controversy, despite being more effective in terms of weight gain, less expensive overall, and able to reach more children.

This is not to say that local products and remedies can't be effective in treating SAM. These should be considered as alternatives when RUTF isn't available and are up to the choice and tradition of every family. But on a whole, they're not working because we still see astronomical SAM rates.

As a policy, the government should look at what is the most effective treatment for SAM and should rely on domestic and international medical research. The recipes used by many groups in the field to treat SAM have not been clinically tested or even evaluated for their nutrition content. A critical element for the care of a SAM child is knowing their caloric and micronutrient intake. These local recipes should undergo clinical trials and evaluations if they are to be used as medical therapy.

SAM treatment is different than Moderate Acute Malnutrition (MAM) treatment: Children with SAM are at a high risk of dying and require a specifically therapeutic formulation for optimum weight gain, children with MAM do not. Local production of the foods recommended by DWCD would be perfectly targeted for MAM treatment. Treating the larger MAM population with local foods serves as a preventative measure and could also employ self help groups, community groups, use local produce and stimulate the local markets. These two feeding methods should be complementary, not exclusive. Local supplements are also ideal for ensuring that a child who has recovered from SAM does not slip back into malnutrition.

RUTF requires a high standard of quality control that villages cannot guarentee: RUTF should be produced in a facility that has been certified as meeting international food quality standards (Codex & HAACP regulations). RUTF production is tricky. Micronutrients and other ingredients need to be weighed precisely. There are many potential contaminantes from the aflatoxins in the peanuts to bacteria in milk power and oil that could make the product more harmful rather than beneficial. With their weak immune systems, even a small contamination could kill a SAM child. A village level nutrition supplement for SAM cannot effectively provide the high standard of quality assurance that is required for SAM supplements. RUTF production sites need sophisticated laboratory equipment on site and dedicated food scientists to check for toxin levels, bacteria, and other contaminents daily, in addition to food quality testing such as making sure that nutrition levels are as specified, that moisture is not present in the product and a whole number of other checks. These in-house labs also should undergo regular external quality assurance tests.

International success: RUTF has done wonders in reducing the malnutrition load and in responding to nutritional crisises across Africa and Latin America, especially in Malawi and Ethiopia. There are many studies that have compared RUTF's effectiveness vis a vi local alternatives and F100,F75: Each time RUTF comes out on top. Ethiopia, Malawi, Niger, South Africa, Cambodia, Mozambique, Haiti, Dominican Republic, and shortly, Nepal, all have or will have national level production of RUTF. MSF, UNICEF, WFP, Clinton Foundation, WHO - and the list goes on - all recommend using RUTF to treat SAM. I've included references to a few key international studies on RUTF below.

The way forward - RUTF domestic production: Before Compact started to make RUTF in India, the best of the few options for RUTF procurement in India was the industry leader Nutriset, who makes the original RUTF called Plumpy-nut. While this product is the international gold standard, it is expensive and has to be imported. For India to employ a long-term community based therapeutic care strategy for treatment of severe acute malnutrition, local, non-commercialized production of RUTF is ideal. This will take some time to institute, however. In the meantime there are two manufacturers, Cipla and Compact, who are making RUTF in India (Mumbai and Manesar, respectively). These low cost, high quality products can help us treat the millions of children who have SAM and would be ideal to procure for the national program until local production can be scaled up.

And as I started this posting off, Compact just got their quality certification. I've been to the plant, I've tasted their RUTF, I've met with their CEO, a man with morals who is out to save children's lives and not make a profit. This is the best option we've got. RUTF will allow millions of more children to be treated for SAM at the village level, freeing up NRC space so that Heena and her team can concentrate on just the most severe cases.

RUTF is only a temporary measure and a small part of the long fight against malnutrition. However is it a cost effective and safe means of treating acute malnutrition in children in a public health setting. RUTF is treatment which, if accompanied with proper community-based counseling and support mechanisms, should only be administered to a child once for up to one month. The goal is that by promoting local production of food supplements to treat MAM and through grassroots effort to prevent malnutrition, that RUTF will be used less and less over time.

For further reading, check out:

WHO/WFP/UNICEF Consensus document on "Community Based Treatment of Severe Acute Malnutrition" 2007: http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html

Compact's product: http://www.compactforlife.com/eezeepaste-rutf/

and a whole list of studies to back this up:

• Ciliberto, Michael A., et al., ‘Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: A controlled,
  clinical effectiveness trial’, The American Journal of Clinical Nutrition, vol. 81, no. 4, 2005, pp. 864–870.
• Collins, Steve, ‘Changing the way we address severe malnutrition during famine’, The Lancet, vol. 358, 11 August 2001, pp. 498–501.
• Collins, Steve, and Kate Sadler, ‘Outpatient care for severely malnourished children in emergency relief programmes: A retrospective cohort study’, The Lancet, vol. 360, 7 December
  2002, pp. 1824–1830.
• Collins, Steve, et al., ‘Management of severe acute malnutrition in children’, The Lancet, vol. 368, no. 9551, 2 December 2006, pp. 1992–2000.
• Diop, El Hadji Issakha, et al., ‘Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: A randomized
  trial’, The American Journal of Clinical Nutrition, vol. 78, no. 2, August 2003, pp. 302–307.
• Gross, Rainer, and Patrick Webb, ‘Wasting time for wasted children: Severe child undernutrition must be resolved in nonemergency settings’, The Lancet, vol. 367, no. 9517, 8 April 2006, pp. 1209–1211.
• Manary, Mark J., et al., ‘Home based therapy for severe malnutrition with ready-to-use food’, Archives of Disease in Childhood, vol. 89, June 2004, pp. 557–561.
• Navarro-Colorado, Carlos, and Stéphanie Laquière, ‘Clinical trial of BP100 vs F100 milk for rehabilitation of severe malnutrition’, Field Exchange, vol. 24, March 2005, pp. 22–24,
• Prudhon, Claudine, et al., 'WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children', SCN Nutrition Policy Paper No. 21, Food and Nutrition Bulletin, vol. 27, no. 3 (supplement), 2006,
• Sandige, H., et al., ‘Home-based treatment of malnourished Malawian children with locally produced or imported ready-touse food’, Journal of Paediatric Gastroenterology and Nutrition, vol. 39, no. 2, August 2004, pp. 141–146.
• World Health Organization and UNICEF, Global Strategy for Infant and Young Child Feeding, WHO, Geneva, 2003
• http://www.ahrchk.net/statements/mainfile.php/2009statements/2083/
• and theres many more where that came from
• Thank you to Rebecca and Fabian for helping me understand RUTF and providing countless references

Child Friendly Anganwadis and your chance to help

Goonj (http://www.goonj.com/) an wonderful Delhi-based NGO is sponsoring the Vastrasamman event during Joy of Giving Week across India. In Bhopal two friend-NGOs, Spaandan and Aham Bhumika, are organizing the efforts in MP. Its a drive to encourage and stimulate giving amongst Indians - not neccessarily monetarily, but mostly in used clothes, games, toys, furniture, etc. These goods will be redistributed by volunteers and NGOs across the state to people who would really value these items.

Relating to malnutrition, the many toys discarded by many urban kids that are still in almost new condition can make a huge difference in improving the nutritional status of children in rural areas. Let me explain:

Children who attend anganwadi centers regularly and spend the maximum amount of time there often have better nutrition outcomes than children who never come at all. This is in part because they obtain a supplementary meal there but also because if they spend enough time at the center, the anganwadi worker will eventually have enough time to notice a malnourished child, take his height and weight, and talk to his mother (in theory). If the child is in and out of the center in minutes along with dozens of other kids, this doesn't give the worker enough time to do her job (let alone start with preschool education). You can't blaim mothers for not sending her children the the anganwadi center for longer. They're often a plain room with no windows, stuffy, with nothing to keep a child under 6 entertained. I wouldn't want to hang out there or send my kids there.

who wants to hang out here?

But imagine if the anganwadi center was bright and colorful and full of stimulating posters, toys for kids to play with, educating games, and a cheer that would entice mothers to bring their kids and for kids to ask their mothers to go. In these "child-friendly" anganwadi centers, mothers are more likely to bring their kids, who are more likely going to want to stay, where they will be more likely to learn, and the anganwadi worker will be more likely to assess their height and weight.

I've seen examples of child-friendly anganwadi centers set up by the Spandan Organization in Khandwa, Madhya Pradesh. They started with donated toys, stuffed animals, posters, and games and then got the people from the village to donate paints and building materials from their homes. The whole village got involved in making the anganwadi center cheerful and child friendly, adding a covered area outside the main room where kids could sit outdoors and painting the place with colorful decorations. The anganwadi center was transformed into a place only the poorest people go to when they're sick (and often didn't get care) to a community location centered around maternal and child health. At Spandan's three child friendly anganwadis nutrition outcomes are noticably better than the neighboring centers.

I would encourage everyone in Bhopal to support this effort! Clean out the clutter from your homes and transform an anganwadi center! I also recommend that everyone check out Joy of Giving's website for a lot of volunteer opportunities around India: http://joyofgivingweek.org/

Here are details on the week long drive in Bhopal below:

"Vastra Samman" ( Dignifying Clothing ) Joy of Giving Week from 27th Sept. to 03rd Oct.'09

Joy of Giving Week is a Nation wide campaign aimed at reinforcing giving as a festival. It is an effort to pool in resources that can be channeled to the marginalized. It is being simultaneously organized at 25 cities across the Country from 27th September – 3rd October’09. Give India and GOONJ are prime- moving this campaign.

At Bhopal level "Aham Bhumika" & "Spandan" have taken responsibility to facilitate it. But we certainly can't do it alone and are seeking wider civil society participation in this anecdote event.

AhamBhumika is facilitating "Goonj" in Bhopal for the Event "VastraSamman" during the Joy of Giving Week. Click on for more information at Joy of Giving Week official website.

Vastra Samman ( Dignifying Clothing )
During this campaign we will be collecting clothes, utensils, school material, toys, books, dry ration etc. The material will be distributed to the rural areas as an incentive under cloth for work programme.

You can support us:
(i) By launching collection drive in your colony, office, school, bank, college etc. ( Posters for this will be provided by us)
(ii) By approaching schools, colleges, organizations, corporate, kitty parties, residential societies, clubs, Satsang mandal etc.
(iii) Volunteering us in sorting, packing and transportation of the material.
(iv) By transporting material to our collection centres.

Collection centers in Bhopal where you can submit the material :-
1. Saraswati Collections, Geet Bunglow, Phase II , Ayodhya Nagar, Bhopal.
Contact person - Mr. Ranjan Singh (M) 9993365612
2. Matratva Medical Store, B Sector, Sarvadharam Colony, Kolar Road, Bhopal.
Contact Person - Mr. Subrat Goswami (M) 9826472718
3. Mona Resturant, 9-A, Saket Nagar, Bhopal.
Contact person - Mr. Yogesh Vaidya (M) 9826492924
4. HRLN, 10-B, Aman Complex, 2nd Floor, Above Noble Electronics, Govind Garden, Near Apsara Talkies , Bhopal.
Contact Person - Mrs. Shubhra Pachouri (M) 9993928903

I think some more sites will be added to this list next week when I'm in Bhopal, if so I'll update this post.

For any query please e-mail us at ahambhumika@yahoo.co.in or call Mr. Subrat - 9826472718 or Mr.Yogesh - 9826492924

When things work

Today I witnessed democracy...

I had a meeting scheduled with the Jhabua district director of the Department of Women and Child Development (DWCD) - the department in charge of anganwadi workers, the village health workers who are the government's first line of defense against malnutrition. We're working with DWCD in Jhabua to train all anganwadi workers, anganwadi helpers (who right now don't do anything more than cook, but who have enormous potential), and village leaders in various aspects of malnutrition identification, treatment, and prevention. We were supposed to meet to finalize the training schedule.

Just as I sat down for my meeting with Mr. Jaura, a man donning a dhoti and the longest ear-hair I've ever seen barged in and sat down right next to me with a sheet of paper. He said he came from a remote village outside of Meghnagar, where there was no anganwadi worker. He handed Mr. Jaura a handwritten list with the names of 310 children he counted in his village (there should be 1 anganwadi worker for roughly every 100 children) and also listed out the various ailments children had - diarrhea, malnutrition (who knows how he measured), fevers, etc. He demanded that DWCD place an anganwadi center in his village.

Mr. Jaura immediately ordered an inspection of the village and got his staff started on the neccessary paperwork to create an anganwadi center in this village.

I was happy to wait my turn sipping chai while this whole process went on. About 20 minutes and DWCD was on their way to increasing access to anganwadi health and education services to one more village.

Of course this was just the first step in a long process to establish a new anganwadi center. And given the fact that the list of anganwadi centers the government says it opperates does not actually match up to the ground reality - we'll wait until we see children sitting on the floor eating and learning until we call this episode a complete success, but this is a step in the right direction and proves that in order for things to work we need the dedication from people like my long-ear-haired friend.

The rural poor are afforded numerous benefits and services from the government, but unfortunately many people are not aware of these rights and therefore do not receive the benefits. The times I've seen the system work the best are times like this when rural people take it upon themselves to demand these services from the government.

I'm going to try to make it out to this village soon to see where this man is coming from and what prompted him to come to the DWCD with this request. Will update!

NREGA and the New Deal

http://www.nytimes.com/2009/08/28/world/asia/28iht-letter.html



I'm encouraged that a variety of news outlets have been covering government poverty alleviation schemes in India. I'd like to highlight another article from the New York Times, "Smart Step to Help India's Rural Poor." I agree with the author, Akash Kapur who observes that there's something different about the National Rural Employment Guarantee Act (NREGA) as compared to other poverty alleviation programs in India's past and present.



NREGA is a government work scheme that's been around since 2005. It promises 60 inr per day of work and 100 days of work a year for men and women below the poverty line (same wage for men and women). In order to qualify for the scheme, all candidates must register with their panchayat (village counsel) who administer the program at the local level. Qualified workers each receive a card which they need to keep to record days worked and wages received. The type of work is unskilled manual labor in projects deemed important for rural development - roads, wells, school buildings, etc.


I view NREGA as India's Works Progress Administration (WPA), the New Deal institution which employed millions of Americans in the 1930s. During the Great Depression, the WPA, an act of Congress, was the country's largest employer and used its millions of dollars and its massive labor force to bring about many public improvements such as roads, bridges and important buildings. It brought millions of Americans through the unemployment and the hardship of the depression and also, according to some economists, helped the economy on the way to by spurring consumer spending.

WPA employed most of America until the economy recovered by the early 1940s and America entered into World War II, spurring an industrial boom. In the late years of WPA, the program focused on providing vocational training to WPA employees to make them eligible for factory work.




In the ideal world NREGA would function somewhat the same way (without the war), by employing rural India until the rural economy catches up with the rest of India and the private sector can take over. Looking forward, NREGA should start to focus on providing job skills to its workers and not just a wage they become dependent on. Authorities and civil society should work to ensure that all BPL populations have access to NREGA and they they're given their promised amount of work days (which all too often doesn't happen in very rural areas). NREGA, like all public schemes, should be monitored extremely closely to ensure that corruption is limited and jobs and funds reach the people who are in the most need and that the projects truly benefit the community.

NREGA has potential to outdo its 1930's counterpart. With some of the best minds in government being put in charge of implementation, with the impressive reporting and accountibility systems being developed, and taking into account results we've already seen, NREGA just might change rural India. NREGA will be nothing short of revolutionary if it can start providing workers job skills, filling the gap of skilled labor that many analysts claim is retarding growth in India.

Take a look at NREGA's website and you'll already see something different. http://nrega.nic.in/
has an impressive amount of information and data for a government website, even down to the panchayat level and individual card holder level! You can see how many hours an individual worked, when, and how much they were paid. All accounts are published (at least in theory). There's even a section for reporting irregularities and for conducting social audits. And a step further, they've published the results of corruption investigations: http://nrega.nic.in/State_details.pdf

NREGA isn't and won't be without the flaws of any program being implemented on a large scale through the India bureaucracy, but it is an encouraging step to help the rural poor.

Paper Rations

http://www.tehelka.com/story_main42.asp?filename=Ne290809the_paper.asp

Tehelka gives a great analysis of the challenges of India's Public Distribution System (PDS). Despite the many criticisms of this system (and they will come up in this blog), it still amazes me every time I think of the shear scale of this system that it actually works. The PDS system is the largest food distrubution scheme in the world, serving more than 320million people - more people than the whole the US.

Even with its problems, the PDS system is crucial for many of the families that I've come in contact with. It tides many families over through hard times and cushions the blows of bad crops or sickness.

That said, the system does clearly need an overhaul. I've met countless poor families with malnourished children who don't have ration cards. I've seen PDS shops that never open. I've seen PDS rations being sold on local store shelves. There are set quotas of 28kg, regardless of family size. Spandan, an NGO in Khandwa, MP, has calculated based on surveys with hundreds of families, that the 28kg rations given to a once a month family usually only feeds the family for a fortnight.

More strigent accountability structures are needed. Rations should be doubled or tripled, especially for tribal families. PDS shops should be well-stocked and open everyday to increase accessibility to families like those outlined in this story. PDS should also include essential nutritrients like vitamins and fruits and vedgetables. And we must recognized that while PDS is an important social safety net, it is not a cure for malnutrition. Other social systems are neccessary to make sure there is education given to communities to prevent malnutrition and that services for identification and treatment of malnutrition are easily accessible

While corruption and logistical problems abound in the PDS scheme, I think its right that Tehelka and civil society approach any type of cash transfer scheme with caution. Cash disappears easily - either to government pockets or the hands of debt collectors. I agree with Biraj Patnaik, who "says replacing the PDS with cash transfers is like “throwing the baby out with the bathwater""

The Women's Crusade

http://www.nytimes.com/2009/08/23/magazine/23Women-t.html


Nicholos Kristof and Sheryll WuDunn write a great article on how the empowerment of women can be the silver bullet we've all been looking for in development.


One of the most relavent points the authors bring out in relation to nutrition is the spending habits of poor men versus poor women:

"Our interviews and perusal of the data available suggest that the poorest families in the world spend approximately 10 times as much (20 percent of their incomes on average) on a combination of alcohol, prostitution, candy, sugary drinks and lavish feasts as they do on educating their children (2 percent). If poor families spent only as much on educating their children as they do on beer and prostitutes, there would be a breakthrough in the prospects of poor countries. Girls, since they are the ones kept home from school now, would be the biggest beneficiaries. Moreover, one way to reallocate family expenditures in this way is to put more money in the hands of women. A series of studies has found that when women hold assets or gain incomes, family money is more likely to be spent on nutrition, medicine and housing, and consequently children are healthier."

Hard to admit, but its the truth we've seen too often in the field. Bad spending choices are often a contributing factor to malnutrition. I've seen huts with a malnourished child and a DVD player. Families will often opt for a satellite dish, even if that means less nutritious food for the children. The tribal areas of MP are especially hard hit by alcoholism, which often leads to domestic violence, depression, and less money for nutrition and education. Less sinister, busy parents will often buy a few packets of biscuits a week to feed their child - not realizing that while they are providing calories, they're not providing nutrition. Biscuits cost a lot more than making a nutritious dal and roti.

With money in the hands of women, I'm sure, as the authors observe, more resources will be spent on nutrition, medicine, and education. The resourcesfulness of poor women to provide for their families is inspiring. Of course the solution is not that simple. Men cannot be left out of development. A change in long-engrained mindsets against women is required. Age-old prejudice's and customs must be overcome. Alcoholism must be addressed. Financial education should be given and fiscal responsibility needs to be taught. Women need to believe in themselves and men in women. But at least we know where the focus should be.

Check out the rest of the articles in this series which all give great insights into the power of women in development.

Posts from realmedicineblog.org

Below you'll find a series of entries from my blog posts on Real Medicine Foundation's blog, realmedicineblog.com.

Since the beginning of my work in malnutrition I posted from time to time on the RMF blog on my findings and the developments of RMF's Malnutrition Eradication Program. I include these posts for your reference as a lot of this serves as a good background to my work and my process learning about malnutrition in India. I decided to start a blog specific to malnutrition, in addition to blogging on RMF's blog about my programmatic work, in order to share my learning experiences and observations from the field. While I still might crosspost on some items, this blog will serve as more of an unbiased reference for those who want to learn more about malnutrition from someone who is figuring it out.

Malnutrition in MP in the news

http://www.ndtv.com/news/india/madhya_pradesh_epicentre_of_hunger.php

NDTV recently covered the state of malnutrition in the districts where RMF is working in Madhya Pradesh. They give a great overview of the challenges we are facing.

Field Report from Southwest MP, June 2009

Widespread malnutrition in Madhya Pradesh, India – A note from the field
Jhabua, Alirajpur, Khandwa, Khargone June 2009

Malnutrition is one of the most serious and large scale health problems facing the Indian state today:
· 46% of children under 5 in India are malnourished
· Over 60% of the children under 5 in Madhya Pradesh are malnourished – the country’s highest malnutrition rate
o Out of these 6 million malnourished children in MP, 1.3 have severe acute malnutrition (SAM) and another 1 million have moderate acute malnutrition (MAM) [1]
o MP’s tribal districts are the worst hit in the country because of their cultural, geographical, and economical isolation with up to 100% malnutrition in some villages.

Children with severe acute malnutrition have extremely high mortality rates – between 20-30%[2] - a rate of death approximately 20 times higher than well-nourished children. Malnutrition is closely tied to MP’s infant mortality: one of the highest in India, with 72 out of 1000 children dying every year. This rate translates into an estimated 130,000 children who will die every year. Malnutrition is one of the largest contributors to this alarming rate, constitutes 22% of the country’s disease burden because it severely weakens a child’s immune system, raising their mortality rates from common diseases such as pneumonia, malaria, and diarrhea.

The millions of children who do survive childhood will be forever affected by malnutrition: children who have been malnourished in the first 5 years of life will have limited mental and physical growth capacity as compared to a well-nourished child. There is evidence that a malnourished child will someday have children with low birth weights, perpetuating the cycle of malnutrition

Malnutrition is rampant throughout almost every town in southwestern MP. While traveling through the districts of Jhabua, Alirajpur, Khandwa, and Khargone this June we found malnourished children in every other household at best, in every household at worst.

Southwest MP has been one of the states worst affected by malnutrition in India for decades. While Madhya Pradesh’s state malnutrition average of 60% malnutrition in children under 5 is already “extremely alarming” according to the Global Hunger Index, malnutrition in the southwestern tribal areas of the state is even more concerning. According to Rural Health Commission the proportion of underweight children in these districts can range from 61-96%.

Madhya Pradesh not only has the highest rates of malnutrition in the nation, but also the accompanying highest rates of severe acute malnutrition (SAM). The District Family Household Survey (DFHS-III) estimates that nearly 12% of children under 5 in MP have SAM. This amounts to nearly 1.3 million children who are dangerously underweight. Considering that the medium case fatality for SAM in India is 23.5% (IAP 2006), over 300,000 children are in danger of death this year. There are also another 1 million children in MP who have moderate acute malnutrition (MAM) and who can become severe after just one bout of illness.

The field reality in Southwest Madhya Pradesh matches the statistics. In many villages we visited, 9 out of every 10 children we screened had some degree of malnutrition, with roughly 2-3 out of 10 children presenting with severe acute malnutrition.

Looking forward, a cause for great concern:

The current situation right now in Southwestern MP is alarming, especially in the context of the deaths reported last year during the monsoon season. We can only expect this year to be worse. Seasonal migration, the economic effects of the delayed monsoon, a particularly bad harvest last year, and higher food prices this year all will compound the already dire situation.

Local NGO workers in Khandwa give the season between June and October the dramatic but not inaccurate title, “the season of death.” Each year the monsoon comes at the time when families are the most food insecure, running towards the end of their stocks from the last harvest. The monsoon brings back migrants who were away from their villages for seasonal labor where they often become malnourished because of the higher food prices and unsanitary conditions in the major cities where they migrate. The monsoon brings with it the yearly bout of waterborne diseases, diarrhea, and pneumonia. Entire families are required to work during this period, leaving young children the most vulnerable to improper feeding and care.

According to data collected by the NGO Spandan in Khandwa, last year over 55 children died in just 22 blocks that were monitored and recorded in the Khalwa block of Khandwa. There is nothing unique about the Khalwa block besides the fact that it was closely monitored. Similar conditions are found throughout tribal MP and similar death tolls can be expected throughout Southwestern MP.

Last year child deaths started in June, continued increasing throughout July and August, and peaked in September.











The monsoon and all the waterborne diseases that it brings will cause a massive spike in malnutrition cases like it does every year. This year the monsoon will also bring with it, economic woes that will further limit individuals’ ability to prevent and treat malnutrition. The monsoon is already a week late and isn’t expected until the end of June. This late monsoon has the potential to cause an economic crisis for some families. I observed while driving through many of the states in Southwest MP that many farmers have already planted their seeds, anticipating a timely monsoon. Even with a week to 10 day monsoon delay and with the current heat wave, there is a good chance that those farmers without irrigation (the majority) may lose their seeds before the monsoon comes. If this occurs, these farmers will have to take out loans to get new seeds, putting them further into debt.

Little improvement since last year

Despite a renewed focus on malnutrition by government, media, and NGOs in Southwest MP, there has been little improvement from this year to last year.

In a study conducted by the Bhil Rural Community Health Centre in Jhabua[3], it was found that only 10% of the children screened for malnutrition recovered from May 2008 to May 2009 (not all children could be relocated in 2009, but the majority revisited, see Annex 1). In only 14 villages we found 609 malnourished children out of 3,115. This 20% malnutrition rate is low for the region, but these are all urban villages located fairly close to the Jhabua market, are somewhat more prosperous than other areas of Jhabua, and are villages who receive access to Real Medicine Foundation and Bhil Health and Literacy Society resources (the RMF malnutrition eradication initiative just launched last month, so improvement who this initiative is still hard to measure). The Jhabua NRC is currently filled over capacity with 21 severely malnourished cases.

In Khargone we’ve seen similar lack of improvement. The Spandan organization did a rapid assessment of 177 children in the Jhirniya block of Khargone in December of 2008 (see annex 2)
- Out of 177 children, 107 (60%) were found malnourished
- 30% were in grade III and IV alone.
- 100% of families surveyed answered that they did not have enough food to carry them through the year, with 60% taking out loans.
- 50% of the families do not attend anganwadis for a variety of reasons

When we visited 3 out of 8 of these villages this June we were only able to track down 15 of the children because the majority of the families had migrated or were out in the fields. Out of those 15 children, only one had improved, the majority stayed the same, and 4 got worse.

Spandan also reports that even after all the interventions last summer in Khandwa, child deaths due to malnutrition carried on until November. They report that 6 children died between October and November and that the malnutrition rate remained at above 62% of children under 5 (see annex 2).

Other districts in the area as equally as alarming. Spandan reports that out of 8 villages surveyed in Burhanpur, 12 children had died between June and November of 2009. These villages saw malnutrition rates of 75%, with the overwhelming majority (83%) of families choosing to pay private doctors instead of seeking government help.

Current capacity to identify, treat, and prevent malnutrition is low in Southwest MP
The high rates of malnutrition in this region are especially concerning because of the weak treatment and preventative care infrastructure and services available at the community level. Right to Food estimates that Integrated Child Development Scheme (ICDS) currently only covers 36% of MP’s 0-6 population and 30% of the pregnant women. The Anganwadi workers – village health workers who the corner stones to the ICDS scheme - are absent, officially and unofficially, from many towns. Anganwadi workers we were able to track down were insufficiently trained, had irregular attendance records, and rarely made home visits. Adequate supervision of anganwadi centers appears to be lacking. None of the anganwadi helpers, who spend considerable amount of time with the children had been trained.

The anganwadi centers in Khandwa did not help prevent the deaths of children. In fact, 80% percent of the children who died in Khandwa were registered at the anganwadi center.









This figure is not surprising, given the state of many of the anganwadi centers that we saw throughout Khandwa and the other districts. Anganwadi centers we viewed were dark and poorly ventilated. They most often lacked sufficient stock of essential medicines such as oral rehydration solution (ORS) and rarely had scales. The quality of the food served at Anganwadi centers was extremely poor during the feeding times we observed. The packaged foods served were often broken rice with a few bits of broken daal. Mostly children over two years old would show up alone for food and leave. Pregnant and nursing mothers and their babies were visibly missing from the anganwadi centers.

Anganwadi workers face huge challenges to carrying out all the tasks required of them with limited resources and limited time. In the village of Dhabia in the Khalwa block of Khandwa, the anganwadi center caters to over 90 children on average who come for feeding everyday. With this large number, about the only part of her job the anganwadi worker has time for is to prepare and distribute food. The scale at this center was buried in a back room and brought out for our benefit.

The anganwadi center in Damkheda, Khargone was even more alarming. We visited this village twice in two weeks. The first day, the anganwadi worker never showed up. The anganwadi assistant, who had no idea how many children were registered, said the anganwadi worker lived in a few villages away along with all the records and the scales. In this village we found 4 severely malnourished children and almost no immunizations or knowledge about ORS. When we met the anganwadi she claimed that no children in the village are malnourished, when in fact 2 children sitting in the same room were.

Nutrition Rehabilitation Centers – absence of F-100, F-75 and patient reluctance to attend
NRCs are already filling to capacity. It is most alarming that out of all the NRCs we visited, only Khandwa’s NRC is using F100 and F75. In all the other centers throughout the country, only milk and some vitamin supplements are being provided. Most children are given mixed diets, with little to no, measurement of caloric intake. We have no way to be sure that the children are receiving the most appropriate diet as outlined by the WHO and IAP.

Many families refuse to go to NRCs because of a whole range of issues; they miss essential house and field work, have to leave their other children at home, and are uncomfortable at these centers. Many families will check their child out before treatment is finished, leaving the child at risk for relapsing and further deterioration. Out of at least 20 families I have personally referred to the NRCs, only 1 had decided to stay to receive treatment.

NRCs also lack the capacity to treat the overwhelming volume of children who require care. Currently there are roughly 160 NRCs which spread across the state with approximately 2500 beds to treat 1.3 million children.

“Bengali doctors” and “quacks” are making the problem worse

For a variety of reasons, many families are resorting to paying money to private doctors for treatment of severe acute malnutrition and related diseases. The principal reason is that these centers don’t require patients to be an inpatient, so parents prefer one day treatment to 14 days in one place. Many of these families have also been failed by the NRC before. There are countless stories about children who go in and out to the NRCs with no results (currently conducting a survey to measure this). Spandan found that in Burhanpur, 83% of families took their kids to private practioners. Not all of these are bad, but some can be dangerous.

Ramnaray, below, was brought to the NRC 4 times according to his parents. When he kept getting worse and contracting respiratory infections his parents finally took him to a “Bengali doctor.” This doctor burned him with an iron to get right of the infection. His parents and the local villagers believe that it worked.

What can be done?

The problem in Southwest MP is overwhelming, but there is plenty of scope to change the situation. Some activities will need to be large scale and coordinated by the government and large NGOs. Even before the official launch of our malnutrition program, RMF and the Bhil Health and Literacy Society have been working actively in a few villages. In Umri, where we’ve been most engaged, we’ve seen a dramatic decline in malnutrition of 37%. This type of pattern can be expected as RMF and other NGOs engage local communities.

- Community level involvement in all planning processes for identification, treatment, and prevention of malnutrition.

- Immediate emergency response team to address the problem: This should be a consortium of all government departments and NGOs that relate to these malnourished children and their families so that relief efforts can be coordinated based on capacity and core competencies of each organization involved

- Provide on the ground job training to both Anganwadis and Anganwadi helpers on malnutrition identification, treatment, and prevention

- Increased AWC, NRC, PDS, and block hospital supervision and conduct random spot check. Will hold AWW and other government officials accountable

- Make AWCs child friendly - with just a donation of second hand toys and some paint, a local anganwadi center can be transformed into a place where children want to attend and will stay longer.

- Mobile clinics for remote tribal areas

- Production of local supplements for moderate malnutrition by village level self-help groups and social businesses

- Create long-term community-based therapeutic care program to continue on throughout the year to decentralize malnutrition care and treatment and make it more accessible to children residing in interior villages.

The Hidden Hunger

May 31, 2009 in Africa, In the news, India by Caitlin McQuilling

http://www.nytimes.com/2009/05/24/opinion/24kristof.html
Nicholas Kristof writes about malnutrition in Africa, but touches on some of the same issues we face with our malnutrition eradication program in India. Malnutrition in India is most often not a result of the lack of food, but a lack of proper nutrition compounded by a lack of education about what constitutes proper nutrition and young child feeding practices.

Malnutrition eradication approaches in India over the past 30 years have focused on food security, trying to ensure that families across the country have access to staple foods. This has resulted in a well developed food distribution system, even in emergency circumstances, but has not achieved reduction in malnutrition – there actually have been increases in some areas.

I’ve included two maps below, the first which maps malnutrition for children under 5 years old, and the second which maps food insecurity in India – rating households’ access to food. You’ll see that there is a close connection between food insecurity and malnutrition, but this isn’t the only element at play. Madhya Pradesh, the state with the highest, “extremely alarming” malnutrition rate is not the state with the highest level of food insecurity.

The causes for malnutrition are extremely complicated in India and vary district by district. Diseases such as tuberculosis and HIV are drivers of malnutrition for many children, and seasonal diseases such as diarrhea and pneumonia exacerbate malnutrition in other children. Issues of sanitation, hygiene and access to clean water are closely tied to malnutrition.
The majority of children and pregnant women in MP, 70%, are anemic. Protein deficiencies are rampant. Most children do not have access to vitamin A or basic vaccinations. Fruits, vegetables, and proteins rarely compliment meals of rice and pulses.

And there are other, more complicated factors at play. I met one family a few weeks ago whose three children were malnourished, the baby severely malnourished. Our village nurse tried to convince them to take the child to the Nutrition Rehabilitation Centre, but they refused to go until a wedding in the village was over. Tribal weddings in MP last for days and nights. They are high energy and intense. I attended the last day of the wedding, which consisted of the entire village of about 200 people singing, dancing, and waiting in the sweltering sun from 10am to 6pm. Many of the families carried snacks with them to get them through the day until dinner was served. This family didn’t. I kept an eye on them all day, watching the baby lull around in lethargy, without being breastfed. He didn’t cry, or laugh, once. The older girls were weak and didn’t play with the other children. Finally dinner – fresh goat, rice, and dal – was served by the groom’s family. I was looking forward to seeing the family eat. As I stealthily observed from across the crowd, the family had a bite or two of the food and then packed the food neatly away in a plastic bag along with empty bottles they had collected during the day. It was heart breaking, perplexing, and probably unjustly on my part, angering. The baby perked up and started to giggle even after receiving just a few bits of rice. The family was starving in the presence of abundant nutrition. They could have easily gotten seconds just as many of the other families did.

I asked my local colleagues right away for an explanation of what I saw and an intervention. They pointed out to me that the husband was not present at the gathering and that often amongst people in this particular tribe women will not eat before their husbands. They would follow up with the husband later, but couldn’t do anything then.

The situation became even more baffling, when my colleague who knows the family told me that the husband and father is a chef at the local school. Clearly he has sufficient access to enough nutrition to bring home to his family.

This colleague spoke to the father later that night and convinced the father to bring the child to the nutrition rehabilitation center the next day. The baby will get treatment and gain enough weight to be back on a normal growth pattern – but what then? How can we guarantee that the baby will not just fall back into malnutrition?

The only thing we can do now is to stay close to the family, visit often and counsel both the mother and father (who seems to be the one making decisions about food in the household) about proper nutrition. While we spend time with them, we’ll also try to understand the root causes of malnutrition in the family. This is not going to be easy or immediate. Our local health workers need to gain the trust of this family in order to understand the problem and solve malnutrition at its core.

And this is what RMF and our partners in the field will have to do in every case to identify, treat, and prevent malnutrition. We will work with groups who are on the ground and who know the local populations the best. We realize that to cure malnutrition in India, food isn’t the only answer. We can pour all the money in the world into the problem and that won’t break the cycle. Sensitive, micro approaches are needed to ensure that our program is effective, efficient and will create long-term change.

The Perfect Storm

Malnutrition: The Perfect Storm and why we need to act now

May 11, 2009 in India by Caitlin McQuilling

Last week I blogged about our program launch. We realize that it is unusual in the NGO world for an organization to launch such an ambitious initiative in such a short period of time. While in the ideal world we could have spent many more months planning, doing baselines assessments, and fundraising, we know that we need to act as soon as possible with the resources we have because if we wait too long human lives are our opportunity costs.

Right now there are 1.3 million children in Madhya Pradesh alone with severe acute malnutrition who are in danger is dying. There are another 1 million with moderate acute malnutrition who only need one case of diarrhea to bring them to the brink of death. These children can’t wait for bureaucracy or months of strategic planning.

The situation has been bad in Madhya Pradesh for years. Since the hundreds of deaths from malnutrition last year, not much has changed on the ground except that the situation has gotten worse. Over the next few months, we are facing the perfect storm for malnutrition in southern Madhya Pradesh: a situation that has already been dire for years will become even worse because of drought, a poor harvest that still forced mothers to be away from their children for long stretches of time, inaction during elections, seasonal migration and the coming monsoon which will bring its yearly bout of disease. This is an emergency.

I’ll explain.

Timing
The harvest in MP lasted from March-April. During the harvest Nutrition Rehabilitation Centers (NRCs) were virtually empty (of the 10+ I visited in April, I only saw 0-3 patients, maximum, in 20 bed facilities). Families often migrate and women need to work in the fields, regardless of the age of their children, to sustain their families. During this time children are left home alone, usually with insufficient food and babies are not breastfed. At the end of the harvest each year, according to every local health care worker we spoke to, the case load of malnutrition spikes, overflowing NRCs because
1) Anganwadi workers, NGOs, and other health care workers who do not visit families in the fields can find families when they return to bigger district centers
2) the parents finally have time to bring the children in
3) the children have deteriorated so much by the end of the harvest that they are finally sick enough to cause concern
4) mothers find they can no longer breastfeed their children after being gone from them for extended periods of time
This year the situation is even more worrying because of elections and the Election Moral Code of Conduct, health care has virtually come to a halt at the field level. Health workers have been called on election duty; others have used the elections as an excuse to not come to work. New health care workers, even at the lowest levels, cannot be hired and ineffectual ones cannot be fired. Basic medications are expected to run out across the state because the new state drug procurement system has not yet been enacted because of elections and no drugs were ordered for this quarter.

Now that work can go on again from the government side and the NGO side, it may soon be too late. Monsoons will hit, which will make many tribal villages inaccessible for months. With the monsoons every year come a surge in diarrhea cases, which speed malnutrition, and other sicknesses such as malaria and dengue which often have higher mortality rates for children who are already malnourished and have weak immune systems.

Those children we don’t miss because of the monsoons we may miss because of migration. During the months from May-August as high as 50% of the population in southern MP may migrate to neighboring districts or states in search of work. Once these communities have migrated, they are lost within the system, since they are hard to find, let alone convince them to bring their children to hospitals in areas even more foreign for them than the district hospital in their home district. With no systems as yet to track migrants, it’s extremely difficult to offer them health services along their migration routes.

Drought
On and off draughts for over two decades have fueled poverty and migration in Southern MP, affecting millions of people. The draught first last season, and now this season which brought low crop yields is only exacerbating the poverty which causes malnutrition. I spoke off the record to a high level official in a government bureau who monitors drought and harvest. He told me that there was a severe drought affecting southern MP and that the harvests were much lower this season than last. This information is unlikely to come officially however, because speaking about drought and then the required relief is often extremely politically sensitive.
All the villagers we’ve spoke to in Jhabua and Dhar complain of a low crop yield this season, forcing farmers who didn’t make enough money to make tough choices on what to feed their families. Most farmers are forced to borrow money to feed their families and get them through the next season. With village money lenders charging them a minimum of 10% interest per month, many of these farmers never recover from drought and debt and are forced to sell their land, turning them into indentured laborers to pay back their debt.

Failed Government Services
Empty NRC ward in Alirajpur, Madhya Pradesh. May 4th, 2009
On paper, the government’s structures and schemes to alleviate malnutrition are perfect and if rolled out even halfway will bring enormous benefits to the people of India. Indeed, a large part in the battle against malnutrition has been won – government policies align for the most part with best practices and are forward thinking. On the ground however, these policies have not translated into actual services for the people. The slow nature of the bureaucratically swollen system, rampant corruption, and lack of oversight systems have prevented changes and services from being brought to the rural poor who need them the most.
o Slow ramp up of the Integrated Child Development Scheme
§ ICDS and the supplementary feeding at anganwadi centers under that scheme currently covers just 35% of MP’s population (7th Report of the Commissioners of the Supreme Court). If the number is this low on paper, in practice it is even lower.
o We’ve had difficult times finding anganwadi workers throughout Southern MP, especially the district we work mostly in, Jhabua. The NRC’s complain that anganwadi workers never bring in patients. When I have found anganwadi centers in southern MP, they often do not have scales, charts, and basic medications.
o NRCs are good facilities overall, especially for children with complicated malnutrition, but their capacity is insufficient (even if we could get patients to fill them) to meet the demand across the country. There are currently only an approximate 2000 beds at 135 centers across MP to serve 1.3 million patients. These are only located at district centers or larger towns throughout the districts and often prove difficult to access for tribal communities. Many tribal people are also not willing to spend 14 days at an NRC, regardless of the wage compensation given at the centers
This is why RMF is acting now and coming in strong. We’re joining some great partners who are already working in the field on malnutrition. We’re confident that other NGOs will follow us shortly and will be good allies in this battle against malnutrition and time. The government system will catch up as well. It has to. The scale of all health and social problems in India are so large that no one body can do anything without the government, its reach and resources. As we act to fill gaps in the system, RMF and our NGO partners will continue to strengthen and reinforce the government system’s capacity to address malnutrition

Launch of the RMF Malnutrition Program

Malnutrition Eradication Initiative Launch
May 7, 2009 in India by Caitlin McQuilling

After almost two months of planning, field assessments, and speaking to everyone from mothers of malnourished children to politicians we launched the first phase of our malnutrition eradication program in Jhabua, Madhya Pradesh with two trainings in malnutrition identification, treatment, and prevention over the past week. Our intervention will be a long-term, holistic initiative, with not just trainings but consistent onsite activities and follow up over the next two years, but this past week we started with the first step, a training to create awareness and to increase referrals of severe acute malnutrition to government centers.
On Saturday April 25th we called men and women from over 40 villages in the Jhabua district for our first awareness and training session. These participants, all from Jhabua’s Bhil tribe, represented self-help group animators, parents of children enrolled in the Bhil Academy, and active community leaders.
Fabian, Jimmy, and other RMF folks addressed the crowd, in Hindi, and engaged them about issues pertaining to malnutrition. We discussed what causes malnutrition, what it looks like, and how to treat and prevent it. We taught the group simple methods of identifying malnutrition and gave them guidelines on where, within the government system, they can go for treatment.

Standing room only – RMF’s first malnutrition training session for tribal community leaders
Teaching local communities to identify malnutrition is one method to ensure that children are referred for treatment, but also is a strong method of creating awareness, one step towards prevention. Everyone in this audience had heard about malnutrition to some degree and were aware that it is a threat, but most were not aware of the scale and immediacy of the problem in their communities. In a village where between 60-100% of the children have some degree of malnutrition, malnutrition becomes invisible. Emaciated bodies, lethargy, sickliness, these symptoms become a way of life, banal compared to the other daily challenges these families face to survive.

The training was a lot of fun, even though I felt a little out of shape: After comparing upper arms while explaining the MUAC method (measurement of upper arm circumference, an easy way to identify malnutrition in children) with all the women in the group who do manual labor all day, carrying kilos of water on top of their heads, impossible mounds of firewood, and children big enough to walk and run on their own, my biceps are pathetic. These women are tough and will do whatever it takes to care for their families. They just need the resources and knowledge and they’ll take care of the rest.

On Monday May 4th, we had our second training session for 30 men and women representing 10 NGOs who, put together, work in over one hundred villages throughout Jhabua and Dhar districts. During this session we not only trained the trainers – NGO workers who will go out into the field and train the groups they work with – but also received a training ourselves on the challenges that these NGOs face in the field. Elections, drought, migration, and even weddings pose serious challenges to identifying malnourished children and getting them the treatment they need. In their experience malnutrition is caused by lack of information about best feeding practices, migration, lack of proper hygiene, improper weaning practices, not enough space in between children, and lack of vaccinations – all root causes that we see time and again. No one mentioned lack of enough food as a cause for malnutrition.

Out to the villages with the trainees
After both training sessions, we then followed some of the women we trained and their children home to their villages to show them malnutrition identification in practice and to see what they would encounter in their homes.
On Saturday we visited one rural tribal village of 3,000 people where we went on a wild goose chase trying to find the local “anganwadi,” government village health worker. According to the government of India, one anganwadi worker is supposed to be present for every 1,000 people and is supposed to be the “frontline” health worker, the rural communities’ first contact with medical services. Anganwadi workers provide basic medications, basic health awareness, antenatal services, weekly immunizations, and food and preschool education to children under 6. In some areas, these health workers are the linchpin to making dozens of government interventions and services work.

We found 4 schools in the town which the locals said were staffed by teachers seldomly. The local health sub-centre is open a few times a month instead of daily. Locals don’t even bother visiting these education and health facilities because when they get there, there are no services worth their trip. When we finally found the anganwadi centre, we found that the health worker had long since left and the building had been taken over by a family and their cattle: A family with two children suffering from malnutrition in the former/still official anganwadi building.
Even in this town, relatively close to a large town (the locals visit the weekly market in town) with a tribal population which is known to be the better off and more educated of tribal groups, we still found around 6 cases of severe acute malnutrition in the roughly 50 children we saw.

We visited another set of villages after our training session on Monday May 4th. Kauwa, in the Alirajpur district, was a village so remote that I had a hard time even fathoming how they get their basic supplies. As we were speaking to the local anganwadi worker and village mothers, children seemed to pour out over every hilltop, water pump, and shed. There were about 200 children in this farming village. We found another 30 or so shy children who were camped out with their families on the side of the road. These families, migrants from Gujarat, are day laborers for the new road they are building through the district and follow the road as its being built, camping alongside the current construction sites.

Out of the children who we were able to measure, we found that most children were underweight, with a few suffering from severe acute malnutrition. These children, who need expert medical care, were children of the migrants following the road construction. Their parents will not take them to NRC because they have to follow the construction path and are unwilling to spend 14 days in a hospital in a different state.

With so many children in such a remote village which only has one one-room health center staffed by one local woman, it’s hard to imagine that the children can possibly have access to the health services they need. The anganwadi center lacked the scales and measuring tapes to measure height and weight of children and also lacked many of the basic medicines necessary to treat common ailments that the centers are supposed to always have.

We left our MUAC tapes with the anganwadi worker and a promise to follow up with the Women and Child Development Ministry and UNICEF to ensure that this center is restocked with the proper medicines and equipment.

Training mothers, health care workers and NGOs is just the beginning. Once the children are identified as malnourished, they then need to be treated. We made sure during our trainings to speak to each participant individually to make sure they know where the nearest government facility to send a child for malnutrition treatment is located. We will also be following up monthly, if possible more often, with the people we have trained to reinforce the lessons, do onsite training, and to keep updated on the challenges they face.

Next Steps:

This isn’t enough. As we’ve seen time and time again during site visits, for many children government Nutrition Rehabilitation Centers are not an option. Parents are working, mothers unable to leave husbands for blocks of time, migrants are unwilling to visit these centers in a different state, family weddings prevent others from spending 14 days at a government health facility. These patients, with uncomplicated malnutrition need the chance to get outpatient care. Our next step is to bring treatment for severe acute malnutrition directly to the patients so that they don’t have to travel to centers. With proper oversight and stringent follow up, we will be able to treat children with non-complicated malnutrition at home.

This is part of our larger strategy to tackle malnutrition from both the community and facility angles, focusing on the continuum of care in between. The causes of malnutrition are so varied and the problem is so complex, that we need to look at each village as a separate challenge and an individual community to celebrate. RMF, our field staff, and village volunteers will tailor our long-term interventions to the individual communities we’ll serve.