Rage Of A Silent, Invisible Killer Called Malnutrition - Why Shining India Is In Grip Of An Epic Calamity

At the heart of global geopolitics, India is an emerging superpower at 72. But away from the spotlights, here starvation stalks, families battle chronic hunger to stay alive, lack of food starts from the womb, underweight mothers give birth to undersized children, while low immunity snuffs out vulnerable lives. Five years into power, the NDA government faces its toughest challenge. And now, the Vice President of India, Venkaiah Naidu, has sounded out a clarion call for action: 바카라�India needs a ­nutrition revolution.바카라�

Ruby Devi stays put in a darkened room. Neighbours come calling, to drag her out of that corner, to eat, feed her son or breastfeed her daughter. She talks about her husband, Jhingru Bhuiyan바카라�s year-long battle with stroke and paralysis, repeated attempts to get a ration card, inability to buy food or medicines, months of eating just rice, days of having not even a grain at home, the unlit chullah, loans, begging and his death. No expression, no tears, no anger. But as you take leave, she comes alive: 바카라�What will happen to us? Can you ask the sarkar for free food? A ration card?바카라�

Sometimes, some places fall off the map. Dondagada village in Jharkhand, hidden in the maze of undulating hills, tall trees and red mud tracks of Chatra taluk, is one such. Sometimes people, too, fall off the grid of visibility. The family of Bhuiyan, the 40-year-old Dalit who died hungry and ill on July 16, is one such. Faces among 19 crore Indians who sleep hungry every night, among one-third of the world바카라�s ­malnourished, and 25 lakh citizens who die of hunger-related causes every year. A disquieting presence amidst India바카라�s new plenty바카라�consumed by crushing poverty, wracked by malnutrition, inhibited from reaching full potential. How free are they as India turns 72?

INVISIBLE EMERGENCY

Bhadumari village of Vidarbha in Maharashtra lies in the foothills of the Pandharkawada ranges. On a normal day, bright-eyed, barefoot children in school uniform sing-song, 바카라�Namaste.바카라� But none of them are four-feet-two-inches tall yet, the ideal height for an eight-year-old mandated by the World Health Organisation (WHO). Most of them have sabzi with roti or rice at home, but love coming to school for the twice-weekly eggs they get. What else do they like? Fruits, they say: jamun, sitaphal, narangi. Ask them how often they eat fruits, they fall silent. Ask around the village and no mother mentions ­malnutrition to be an issue.

One in three children is stunted in India, too short for their age. One in five Indian children suffers from wasting, too thin for their height. One in four is underweight, too thin for one바카라�s age, reports the Global Hunger Index 2018. 바카라�The problem with malnutrition is that it바카라�s not visible,바카라� says Shawn K. Baker, director of nutrition, Global Development Program, Bill & Melinda Gates Foundation. 바카라�Be it iron ­deficiency or of vitamin A, malnutrition is almost always hidden.바카라� Especially, when ­almost every child is undernourished and small, it ceases to be a 바카라�problem바카라�. What바카라�s worrying is the havoc that malnutrition can cause to a child바카라�s cognitive abilities, brain development, health and product­ivity바카라�often irreversibly바카라�starting in the first two years of life.

Ninety kilometres from Lucknow, the road leads up to Sitapur district of Uttar Pradesh. The slow meandering Gomti river keeps pace. Named after Sita of Ramayana, the area takes pride in its epic legacy. But right now, it바카라�s a cause for worry: Sitapur is among 10 districts in the country that face the highest prevalence of malnutrition. Sitapur also tops in teen marriage and pregnancy: over 36 per cent married women are adolescents, while 8 per cent of the 15-19 age group are already mothers바카라�much higher than the state and national average. Here, just 16 per cent girls get to study beyond class 10.

It is the secret story of India. Three-quarters of the world바카라�s teenage births take place in India. New research shows how the health of children born to adolescent mothers is far inferior to those born to adult mothers (The Lancet Child & Adolescent Health, July 2019). A 2015 study from the Harvard T.H. Chan School of Public Health pinpoints the five most ­important predictors of childhood ­malnourishment, three of which have a ­direct link to mothers: maternal underweight, short maternal stature, a mother with no education, extreme poverty and poor ­dietary diversity. 바카라�Undernourished girls become undernourished mothers, who in turn give birth to low-weight ­babies, perpetuating a vicious cycle,바카라� says Basanta Kumar Kar, country director at Project Concern International.

Doctors across the country are analysing mental maps of communities to understand malnutrition. What they find is an eye-opener: misconceptions, myths and malpractices in the name of customs and traditions, often dictated by elderly women of the household. A team from King Geo­rge바카라�s Medical University, Lucknow, report how in Sitapur, Hardoi and Barabanki areas newborns are routinely denied colostrum, the first milk that provides immunity for life, and fed with meals of honey, ghutti (made of herbs, additives and honey), water, sugar-water or animal milk instead of mother바카라�s milk in the first few days.

Dr M.V. Ramana Rao of SVS Medical College Hospital, Telangana, shows that the baby is not given to the mother in 90 per cent of deliveries, largely due to traditional family practice of first wiping and cleaning the baby before passing it on to a senior family member. It is the family바카라�s ­decision to throw away the colostrum (the first stage of breast milk that바카라�s essential for a child바카라�s immunity), as something dirty and unhealthy in most cases, or giving the baby feeds or formula milk as the first feed, ­instead of breastmilk.

When Dr Manjit Kaur Bal first saw the shrunken duo바카라�a mother and child바카라�she was shocked. The child couldn바카라�t hold his head up because he was so malnourished and the mother was hardly in a better state to take care of him or of herself. As the leader of the Samerth Charitable Trust in Chhattisgarh, Bal has worked for long with some of India바카라�s 바카라�particularly ­vulnerable tribal groups바카라�바카라�people wracked by poverty and hunger, dissociated from development processes, displaced from habitats and livelihood by depleting ­forests and encroachment.

바카라�The tribal food basket has always been ­diverse and nutritious, including maize, minor millets like kodo and kutki, oil seeds like ramtila, along with fruits, leaves, ­rhizomes, mushrooms, meat and fish,바카라� says Bal. 바카라�We have pushed them out of their complementary relationship with ecology, way of life and time-tested nutrition.바카라�

Concerned with the critical condition of the mother and child, Bal took them to a nutrition rehabilitation centre, gov­ernment outlets where severe acute ­malnourished children below five years are admitted with their mothers for treatment. But they escaped within a few days. When Bal caught up with her, the mother said, 바카라�The rains are coming. There바카라�s a lot of work in the fields. If I stay away now, my whole family will miss out on food for a year.바카라� Does nutrition matter when hunger pangs hurt? 바카라�Even today, we offer minimum ­support price to paddy, not to nutritious millets that sustained people for thousands of years,바카라� she says. 바카라�In 72 years, we have changed people바카라�s food basket. It will not be easy to give their nutrition back to them.바카라�

바카라�It바카라�s a man-made crisis,바카라� says Balram, advisor to the Supreme Court on right to food, in Ranchi. Until the 1960s, India had a sustainable agricultural system and natural food security, explains the act­ivist who worked closely with Jayaprakash Narayan바카라�s movement in Bihar. People grew whatever they needed, or gathered from the surroundings바카라�weeds, herbs, fruits, fish, livestock. The consumption of traditional coarse grains, pulses and millets, rich sources of vegetable protein with balanced amino acid profile, was exceptionally large.

The landscape changed from the 1970s, in the wake of the green revolution. Focused entirely on wheat and rice, successive ­governments promoted quick adoption of technology, high-yielding grains, intensive farming, chemical fertilisers and price ­assurance. But pulses and millets, Indian diet staples and inexpensive sources of energy and protein, were ­neglected. A host of indigenous grains, seeds and millets disappeared, while production of pulses declined, as prices shot up. It led to a fundamental change in the way people ate, putting small farmers at the mercy of large ­commercial farmers, and dis­solving the idea of village community. 바카라�From around the mid-1990s, small farmer suicides and starvation deaths started getting ­reported,바카라� Balram recalls.

바카라�The world and India so far has focused on food security and we have achieved a lot,바카라� says Purvi Mehta, Head of Asia for Agriculture at the Bill and Melinda Gates Foundation. 바카라�Having reached that hard-earned goal, the next step is tackling malnutrition,바카라� she says. The impact of the word, however, goes beyond hunger and health바카라�about 40 per cent of school absence in rural India is ­attributed to only one factor: malnutrition. Same is the reason behind about 30 per cent of absence of labourers in rural India바카라�s workforce, Mehta points out.

CAN HUNGER END?

The Sustainable Development Goals, driven by the United Nations and adopted by all member states, talk of ending ­hunger by 2030. The economic toll of ­malnutrition is heavy바카라�with Africa and Asia losing an estimated 11 per cent of GDP every year to it from productivity loss바카라�but the cost of eliminating hunger will also be heavy, say experts (see graphic, p.56). And the cost will be significantly higher for high-burden countries such as India. According to a recent report by the UN Food and Agriculture Organisation (FAO), $267 billion will be required per year from 2016 to 2030.

India바카라�s response is the POSHAN (Prime Minister바카라�s Overarching Scheme for Holistic Nourishment) Abhiyaan or the National Nutrition Mission, set up with a three-year budget of Rs 9,046.17 crore starting 2017-18. A look at the state-wise data reveals that of Rs 3,142.17 crore ­released to states until March 2019, just  Rs 569.92 crores were utilised. The fund ­remains under-utilised in a number of states: West Bengal, Odisha, Goa, Karnataka, Bihar, Maharashtra, Jharkhand, Punjab, Kerala, Assam, Delhi and Haryana.

바카라�Whenever you think of the PM, be it to criticise or to compliment, think of POSHAN Mission and not Narendra Modi.바카라� On March 8, 2018, when the PM launched POSHAN Abhiyaan in the small town of Jhunjhunu in Rajasthan, his dramatic words had nutrition gurus across the country sit up and take note. At the end of the day, malnutrition can be ­tackled only if countries have the political will. 바카라�Nutrition is no longer a sectoral concern,바카라� says Hisham Mundol, executive director, Children바카라�s Investment Fund Foundation. 바카라�Nutrition is an economic, social justice and political issue.바카라�

To senior bureaucrat and former ­mission director of Poshan Abhiyaan, Dr Rajesh Kumar, India always had mal­nutrition on its radar. Two of the world바카라�s earliest and largest schemes to reduce malnutrition in children바카라�Integrated Child Development Services (ICDS) in 1975 and Mid-Day Meals in 1962바카라�were launched by India, apart from a range of 21 policy options on malnutrition since Independence. 바카라�But in 72 years, gov­ernments have changed, fallen asleep, woken up, on and off,바카라� adds Kumar. 바카라�The focus on nutrition has waxed and waned accordingly.바카라�

The drumbeats of shame started rolling from 2007, when UNICEF announced that an Indian child was more likely to be ­malnourished than a child in Ethiopia. Former PM Manmohan Singh called it a 바카라�national shame바카라� that the spectacular GDP growth for a decade and a half had scarcely dented child malnutrition rates. To Dr Rajan Sankar, director of nutrition, Tata Trusts, it has been a 바카라�big implementation and ­targeting failure바카라�. In 2004, the Supreme Court passed a historic verdict for expanding the anganwadi system of frontline workers under ICDS. 바카라�India has paid ­attention to quantity, but not so much to the quality of that system. This is where everything must happen,바카라� says Dr Shankar.

In many ways, POSHAN Abhiyaan will be a 바카라�game-changer바카라�, says Alok Kumar, member of NITI-Aayog, which played an instrumental role in adopting the scheme. For the first time, there are clear definitions and achievable targets, ­nutrition is not being equalled to food, there is multi-sectoral convergence of ministries led by the women and child ­development department, there is the idea of a people바카라�s movement바카라�jan andolan바카라�to take it forward, and there is technology, to get real-time data to monitor and guide the initiative at the grassroots. 바카라�Without all this, the earlier interventions reached only 5 to 10 per cent of the people,바카라� says Kumar.

Dig deeper, listen harder, look longer: a hundred audacious ideas are putting ­social change into action. Hundreds of nutrition warriors바카라�anganwadi sevikas to Swasth Bharat preraks, community ­mobiliser didis to badlav didis바카라�are sprea­ding the good word, engaging people and creating change.

Across Maharashtra, hundreds of ­kirtankars are linking devotional abhangs to the importance of nutrition to the mother and child, and influencing family matriarchs, who otherwise ignore health advisories. India바카라�s poorest and hungriest people, the rat-catching Musahars of Varanasi, are growing kitchen gardens in their backyards. Their diet of rice or roti with salt is now peppered with sponge gourd and squash, pumpkin and bitter gourd. Across Bihar and UP, government medical colleges are integrating maternal, infant and young child nutrition into the undergraduate curriculum. In villages across Chhattisgarh, lactating foster mothers, dharam dai, are feeding children, while bahu, saas and pati sammelan are decoding breastfeeding. In Kerala, healthy baby shows by paediatricians and medical students are encouraging mothers to breastfeed their children well. Women across Jharkhand are now cooking in iron vessels to combat anaemia.

In Rajasthan, villages, the sarpanches are rallying for the nutrition needs of their people, taking part in panchayat workshops and ­comparing notes with peer groups in other villages.

When Shashanka Ala joined as deputy commissioner of Lawngtlai바카라�one of Mizoram바카라�s remote districts bordering Bangladesh and Myanmar바카라�she enrolled her one-year-old son in the nearest ­anganwadi. Though she was happy that he made new friends, she saw that he was coming home with take-home ration in small packets of mostly rice and dal. 바카라�My first intervention was to make sure that hot cooked meals were served in the ­anganwadi,바카라� she says. Further enquiry ­revealed that most children in the area were undernourished. A new and lactating mother herself, and a strong advocate of exclusive breastfeeding, she linked it to the unavailability of fresh fruits and ­vegetables in the region and inadequate infrastructure to cook hot meals. After rounds of discussions with the stake­holders, community NGOs and church ­elders, 바카라�Kan Sikul, Kan Huan바카라� (my school, my farm) was designed, and armed with seeds, compost and gardening equipment, parents, teachers and children started producing their own vegetables. The pilot project proved so successful that it was launched in all the anganwadis and schools in the district.

Far away from Mizoram, tiny toddlers are having a romp in their community creche in Churgui village of Jharkhand. Designed by Ekjut, a non-profit founded by Dr Prasanta Kishore Tripathy and his wife Nirmala Nair, it바카라�s a community ­partnership. The child-carers are chosen by the panchayat, and Ekjut ensures their training. Children get a safe and protected environment, safe drinking water, safety from household smoke, hand washing ­stations, four nourishing meals and learn hygiene바카라�for eight hours every day. 바카라�We monitor their language, cognitive and physical growth,바카라� says Tripathy. 바카라�Most importantly, we maintain a constant ­dialogue with women and the community through participatory meetings.바카라�

Over the past five years, the Ekjut team has been documenting their growth parameters. One file on each child, showing growth charts and graphs and progress from dangerous red zone, through yellow to a healthy green. The outcome has been startling바카라�27 per cent reduction in wasting, 27 per cent in stunting and 40 per cent in underweight바카라�drawing international accolades and coverage in prestigious medical journal, The Lancet. 바카라�It바카라�s an exciting moment. The challenge is to do things in a way not attempted before,바카라� says Tripathy.

It바카라�s playtime now. 바카라�Hijume, hijume (come, come),바카라� invites Saraswati, 27, one of the child-carers. Children pretend to be butterflies, pampargo in the local Ho ­dialect. They, sing, dance, clap and laugh: 바카라�Dup pe pampargo, undem pe pampargo, tingur pe pampargo (sit, bend, stand, dance, wriggle like a butterfly).바카라� The smell of food wafts from a thatched kitchen nearby, along with the clanking of ­stainless steel. The children jump in joy as they are lined up for hand-washing. They sit in a circle, wield spoons and dig into khichdi with boiled eggs. As they drift off to sleep under a massive mosquito net, nine-month-old Pardhan Gop바카라�s mother turns up. It바카라�s her time to breastfeed him. 바카라�They learn new things and eat nourishing food, while we are free to do our work,바카라� she smiles. The sun fades beyond the ­conical Chari Buru hills of West Singhbhum, cow bells tinkle and ­children바카라�s laughter ring out.

바카라�The State shall regard raising the level of nutrition and standard of living of its people and improvement in public health among its primary duties,바카라� says Article 47 of the Constitution of India. But after 72 years of Independence, freedom clearly means different things to different people. But the time has come for everyone to ­declare a new independence: freedom from malnutrition for all.