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.

The beginning of my malnutrition work in India

My start:

Starting RMF’s Malnutrition Program in India

Back in March of 2009, sitting comfortably with a cup of coffee and my laptop, I sat on my balcony in Delhi and read a New York Times article by Somini Sengupta titled “As India Growth Soars, Child Hunger Persists” (http://www.nytimes.com/2009/03/13/world/asia/13malnutrition.html). Living in India for 2 years working in public health, I considered myself a well-informed hand of the development sector. I knew that malnutrition was one of the nagging problems pulling back at India’s development, but the awesome extent to which malnutrition plagues this country was a shock. With 46% of India’s future threatened by malnutrition, to call the problem India’s “a national shame,” in the words of Prime Minister Manmohan Singh, is just the beginning. I had also just coincidentally left my job at the Clinton Foundation's HIV/AIDS Initiative in Delhi and was weighing my options on my next career step. At the time, working for the Real Medicine Foundation in malnutrition was not in my horizen, but then I started thinking.

“What is going on? Why isn’t anyone doing anything for malnutrition? What can we do?” I complained next time I spoke to Dr. Fabian Toegel, Real Medicine Foundation's Honorary Country Director in India. In his very German way of breaking down a problem, Fabian rattled off a plan to combat malnutrition without skipping a beat. Fabian not only is a doctor with his MPH, he has also worked in rural India for the past 12 years: He’d clearly been confronting and thinking about how to tackle malnutrition for years.

Based on Fabian’s innovative approach to tackling malnutrition in India, the two of us sat down and devised a strategy and then set up meetings with partners and key stakeholders to determine the need and feasibility of our intervention. We quickly saw that despite the numerous challenges to working in malnutrition in India, the potential for us to make a large impact is enormous, so we brought our idea to Martina Fuchs, RMF’s CEO. “Eradicating Malnutrition in India” was the title in my email and Martina’s response was “this is fantastic, let’s do it.”

And there, with barely an audible pause between words and the enthusiastic faith of Martina, the Real Medicine Foundation's Malnutrition Eradication program was born.

Our goals are ambitious, the problem is daunting, but we have to do something and we have to start somewhere, so we’re going to start where the problem is the worst, the state of Madhya Pradesh. Our work is cut out for us: 60% of the state’s children less than 5 years old suffer from malnutrition, with an estimated 1.2 million of those suffering from severe acute malnutrition and another 1 million suffering from moderate acute malnutrition. [For more details about the challenge we face and how we plan on tackling it, click here http://www.realmedicinefoundation.org/initiatives/IN4-3-7.asp ]

As soon as we decided to start the program, I left Delhi for 5 months weeks to see the ground realities in rural MP to determine where we should focus and what the most urgent requirements of the communities on the ground are. I met with top government officials, NGOs small and large, doctors, caregivers, and UN organization heads in Bhopal, MP’s capital, to get a sense of the local political situation and the NGO landscape in MP, and then went out into the field. I traveled through the northern districts of the state and the tribal areas of the south, visiting the cities in the middle. After many overnight trains, rickshaws, buses, motorcycles, jeeps, and even an elephant, I’ve seen the overwhelming need for our work, especially in the southern tribal districts of the MP.

From the limited amount of this vast state that I have seen so far, the malnutrition rates in Madhya Pradesh are not statistical exaggerations. The faces of the children behind the numbers are haunting: they are the blank bug-eyed stares of children left behind by the system and society, so skinny they can’t sit up to hold the weight of their heads. The poverty causing malnutrition is as real as the cliché. I met a group of railway orphans who were taken to see “Slumdog Millionaire” by an NGO as a treat, but who didn’t find it at all entertaining because that is their life. I met women who were forced to work the fields and then on their return found they couldn’t breast feed their babies. Dirty water is used for baby formulas. Untreated cases of diarrhea leave children emaciated. Caste bars some state sponsored health workers from entering villages. Naxalite revolution bars health workers from entering others. Frequent migration leads vulnerable populations to alien towns where the food they know to be nutrition in their village is either unavailable or prohibitively expensive. Dangerous misconceptions about nutrition abound from lack of education, such as the village tale that bananas (plentiful, cheap, and nutritious) cause sterility. Mono-crops have limited the nutrition coming from the earth and the productivity of agriculture. The drought this year in southern Madhya Pradesh is only going to exacerbate the dire state of the majority of the rural populations. The future is bleak for most of these children even if they survive childhood.

The poverty in rural MP is compounded by/linked to a number of serious problems within the government and NGO service delivery system. The government has been unable to address rural problems at times, at others complacent, and at worst a counterpart to driving poverty. I’ve seen and heard anecdotes of endemic and systemic corruption, government schemes that never reach the people, NGOs with fake addresses, and empty health facilities. There are many government officials, NGOs, and individuals doing what they can to alleviate poverty and address malnutrition, but there is a lot to be done to fix the system.

Malnutrition in India, like most social, political and cultural problems in this complex and nuanced country, is difficult to wrap your head around. Unlike Africa were malnutrition is mostly caused from the unavailability of food politically or otherwise, in India food scarcity is not the issue. Distribution is certainly a problem, but in a country with the world’s most billionaires, nuclear weapons, and a lunar mission, not to mention the producing the world’s second highest agricultural output, the lack of resources – both money and foodstuffs – is not the issue. From what I’ve seen and heard (backed up by many experts’ opinions), the two predominant causes for malnutrition are the inextricably linked poverty and lack of education. From poverty and lack of education stem the lack of knowledge of nutrition, the inability to treat simple diseases such as diarrhea, dangerous superstitions, indentured labor which forces people to live hand to mouth, and ignorance to public poverty alleviation schemes.

In short, the causes for malnutrition are as multifarious as Indian society and cannot be rooted out in one generation by one NGO one government or by one approach. But is this a reason not to act? Not to work with government for sustainable change? Not to partner with willing NGOs and individuals to affect changes?

Its exciting and scary to start a new program, especially in the complex nexus of politics, science, development, and poverty in which we’re working. There are the days when anything seems possible and when goals seem within reach. Then there is the harsh reality of a system stacked against us, an economic slow-down and donor fatigue. I’ve had to fight the tears of pity, frustration, and anger a few times. It is at times overwhelming to see the scope of the problems we face and is tempting to give up doing anything because its impossible to do everything.

While pessimism has its place in plan Bs and careful scrutiny of approaches, I think we have many overwhelming reasons to be optimistic that our program will work. Over the few weeks in the field the support we’ve received by government, NGO, UN, and individuals throughout Madhya Pradesh for our program has been encouraging to say the least. From a priest who washes leapers’ feet to a doctor who doesn’t take weekends and visits field sites until 2am, meeting the people already in the field and carrying out inspiring work lets me know that we’re doing the right thing with the right people at the right time. We’re going to work with government officials who really want to affect honest change and with individuals who are willing to take risks in order to do what is right.

We could fail. But we also could save one child’s life. Maybe 2 children. Maybe a family. Maybe a village. Maybe 10 villages. Can we stretch it to an entire district? We may even be able to save the children in an entire Indian state. We might actually save 1.2 million children. That’s incentive enough to try.