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.