Blinkered vision

CHANNI ANNAD/AP

If recent indicators are anything to go by the failure to keep food prices down, the proposed national food security Act, the failure to ensure even minimum wages to construction workers at projects for the upcoming Commonwealth Games in New Delhi, to recount a few it seems the country has given up even the pretence of caring about its children or their crippling, unbudging state of malnutrition.

Leaders, after a few statements in support of children in their speeches, have translated their concern into just 4.63 per cent allocation for children1 in Union Budget 2010-11, a national health budget of merely 0.89 per cent of gross domestic product (GDP) and 25 kilograms of grain for each family of the poorest of the poor in the name of food security for children. The minimalistic, so-called national food security Act is really like rubbing salt into the wounds of the poor, as it denies them even the rights conferred by the Supreme Court as far as food security schemes are concerned, many of which concern children, leave alone any expansion into fundamental issues of production, distribution, pricing and control of food.

The same niggardly approach besets all food security measures and other existing services for the poor relating to malnutrition a more and more targeted public distribution system (PDS), unfair estimates of poverty and the application of below-poverty-line (BPL) cut-offs to most essential services, including free health care.

Thus, while technical experts debate the relative merits and demerits of the approach to malnutrition in terms of the highly specific, targeted, narrowly focussed, and usually technical interventions, for child survival, malnourished children continue to slide into food insecurity and disempowerment along with their struggling families as a result of misdirected economic and agricultural policies.

The state of womens health and food security is similarly symbolised by an equally recalcitrant and even more widespread nutritional anaemia. This is a failure in itself as far as womens rights are concerned, but it is also the root cause of low birthweight, subsequent malnutrition and poor child survival. The overall empowerment of women, economic, political and social, also faces resistance that will have to be overcome before more targeted interventions for child survival and malnutrition can hope to be effective. Here, at least, the Womens Reservation Bill moves in the right direction.

Survival of poor children is, in around 60 per cent of the cases, predicated upon their state of nutrition. Yet, child survival strategies seem to be focussed increasingly on narrow, downstream interventions such as the introduction of newer and more expensive vaccines and micronutrient supplementation, at the expense of more comprehensive programmes that offer fundamental shifts in the context and root causes of malnutrition, such as large-scale access to good-quality child care, health care, safe water, information and support to women to breastfeed and to families to care for their children, and easy availability of good-quality complementary foods in early childhood.

Many of these fundamental issues can be potentially taken care of through an enhanced, reformed and much more supported Integrated Child Development Services (ICDS) system2 as well as through specific changes in the existing health care system. The Accredited Social Health Activist (ASHA) programme, for example, can play a huge role in interventions at the household level, including breastfeeding and nutrition counselling. Yet, this important task is not prioritised or incentivised, while ASHA is pulled into a variety of other programmes.

There is also the need to take note of the silent emergency of infants under six months and the urgent support required for their right to food in terms of exclusive breastfeeding. To start with, consider making available to women working in the informal sector the same maternity rights as are given to women in Central government service. This is currently a bizarre two years of full paid leave any time until their children are 18, for two children, and compares with practically nothing at all for over a million of their sisters.

It is true that making these fundamental changes is more difficult than introducing a new vaccine or drug or a vitamin supplement, and that the two approaches are complementary and not mutually exclusive. But what is also true is that our hope that basic and comprehensive measures will be taken care of is belied continuously by the rapidity with which narrow, technical, targeted measures find favour, coupled with half-hearted programme improvements in the above-mentioned areas and continuous policy shifts in the opposite direction where the macro situation is concerned. Thus, in practice, the relationship between selective and comprehensive measures becomes interpreted as adversarial rather than complementary.

The reductionist approach to malnutrition, which sees it as a mere technical or medical problem that should be amenable to quick fixes and as a route to achieve the main goal of child survival disregards many important facts:

First, it is not by mistake that under-five child mortality is considered a barometer of development of a society, and the converse relationship between overall development and child survival, through agencies of literacy, empowerment of women, reduction of poverty, access to health care, overall food security, and so on, has been reiterated time and time again. Thus, we cannot hope to achieve any success on the malnutrition front if there is no movement on these factors or if they are pushed in the opposite direction.

Second, the entire approach to malnutrition is diluted and made ineffective by the reduction of the set of child rights to one of mere child survival. When the Convention on the Rights of the Child, a major pioneering effort even if a relatively weak one compared with the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), proclaimed that children had the rights to survival, protection, development and participation, it could never have foreseen that its champions would focus so hard on the trees of survival as to lose sight of the woods of the comprehensive set of child rights. Once again, this reductionism fails to provide the caring, large-hearted environment within which even strategies that are in themselves not incorrect, only inadequate, can hope to make a dent.

These two points are best exemplified by the fact that while the Planning Commission was persuaded in the last Union Budget to double the allocations for supplementary nutrition of children through the ICDS from Rs.2 a child a day to Rs.4 and to Rs.6 for the severely malnourished, the lack of overall concern for children has failed to see this being implemented in most States even close to a year later.

Meanwhile, the intention to improve the quality of the supplementation (to include, for example, eggs or dairy products or vegetables and fruit, or oils and fats) was made infructuous by the increase in food prices. In effect, all that the minor increase in allocation will achieve when implemented will be to maintain the status quo of a nutritionally inadequate supplement against the price rise.

Finally and this should be more compelling to those who measure interventions by numbers alone without linking them to overall paradigms of development and economics these narrow, mean-hearted strategies of child survival simply do not work.

By setting our sights too low, by focussing too narrowly, by failing to see how one cannot be achieved without the others, we have failed to achieve even survival, as is evident by the recent evaluation of child health and survival strategies practised in Africa and reported recently in The Lancet3. The United Nations Childrens Fund (UNICEF) implemented the Accelerated Child Survival and Development (ACSD) programme in 11 West African countries between 2001 and 2005 but the evaluation shows no difference between intervention and non-intervention areas despite the expenditure of many million dollars. Expectedly, the weak programmatic areas remained those related to malnutrition, community participation and wider supportive measures. The study reports:

Interventions effective in combating under-nutrition, which underlies at least a third of child deaths, were reported by ACSD country teams as receiving low priority in their programme plans. Promotion of immediate and exclusive breastfeeding up to six months of age could have had a large effect on both neonatal and post-neonatal mortality, but seems to have been promoted more heavily in comparison areas than in the ACSD focus areas. There were substantial decreases in exclusive breastfeeding in the focus districts and increases in the comparison areas. It recommends that ...the design of child survival programmes should begin with evidence for the determinants and causes of child deaths

Significantly, as further explanation, it was mentioned that there had been falls in the overall socio-economic status in the ACSD focus districts as well as greater food insecurity in many of the intervention areas.

In juxtaposition, a randomised control trial, reported by The Lancet4, conducted by Ekjut in the poorest parts of Jharkhand and Orissa shows how a 45 per cent reduction in the deaths of babies can be achieved by speaking to women with respect and facilitating the analysis they need to bring their own change with no other intervention whatsoever.

India would also do well to learn from Thailand where concern for children has become an intrinsic part of the political culture and has generated the political will for fundamental structural changes that have borne significant results. Thus, Thailand, as a result of its health, nutrition and poverty alleviation policy using basic needs surveys achieved an annual child malnutrition reduction rate that is about 10 times that of Indias. Starting from a burden of malnutrition of 50 per cent (just over what India currently has at 46 per cent), it managed to cut it down to half in a decade, while we have stagnated for as many years.

How we see a problem and how we articulate it makes a difference to how we deal with it, but we seem to have chosen to look at it from the wrong end of the looking glass, the survival end. We need quite the opposite a magnification of child rights to include the largest vision of children in a society that cares for their survival, growth, development, participation and happiness; that values the hope shining in the eyes of even the most malnourished child and nurtures it; that wants to see every child have the best of this world and be able to creatively make her/his contribution to it; and that offers children equity, not merely the barest minimum required to survive. Perhaps then, we will find the political and social will to invest in children wholeheartedly as a proud and joyful responsibility rather than be so over-concerned with making every paisa spent on the poor count even as we waste, squander, amass, destroy and misuse public resources on every other front with no questions asked.

Let food be one of the main symbols of this caring and large-hearted approach to children let there be an abundance of good food for children wherever they are at home, in anganwadis, schools, crches, health care centres, on the streets, at NREGS (National Rural Employment Guarantee Scheme) sites not a measly 25 kg of grain for them to glean from. Let them have uncompromised, universal, free, quality education and health care with dignity and respect as their right. We must decide as a nation do we want (all) our children to live, or only to survive and start to put our money where our mouth is if we truly value them. We can afford it, and we cannot afford not to. Then we may achieve in the short term at least survival and freedom from malnutrition.

Dr Vandana Prasad is a community paediatrician and joint convener of Jan Swasthya Abhiyan.

1. HAQ. (2010). Children not included in Inclusive Budget: Where is the Aam Bachcha in the budget, Mr FM? New Delhi: HAQ.

2. Working Group On Children Under Six (2007). Strategies For Children Under Six. Economic and Political Weekly, 42(52): 87- 101.

3. Bryce, J,. Gilroy, K., Jones, G., Hazel, E. Black, RE. & Cesar GV. (2010). The Accelerated Child Survival and Development Programme in West Africa: A Retrospective Evaluation, The Lancet, 375: 57282.

4. Tripathy, P., Nair, N., Barnett, S et al. (2010). Effect of a Participatory Intervention with Womens Groups on Birth Outcomes and Maternal Depression in Jharkhand and Orissa, India: A Cluster-Randomised Controlled Trial, The Lancet, published online March 8.