Community health expert and Gandhian Dr. Abhay Bang, is passionate about the issue of child mortality. He and his wife Dr. Rani have together worked in the tribal district of Gadchiroli in Maharashtra for the past 20 years. The Society for Education Action and Research in Community Health (SEARCH), the organisation founded by him, has conducted research on methods to reduce child mortality. A new approach, developed by SEARCH, `Home-based Newborn, Care', is considered a major breakthrough in preventing child mortality.
For the past eight years Abhay Bang has been presenting concrete evidence of the incomplete documentation of the incidents of child mortality by the State. Two years ago the State government appointed him Chairman of the Child Mortality Evaluation Committee. The reports of the committee are crucial to the ongoing Public Interest Litigation in the Mumbai High Court. Abhay Bang presents the issue in an interview to Lyla Bavadam.
Has the infant mortality rate (IMR) in Maharashtra declined satisfactorily?
The Sample Registration System of the Central government recently released the rates for 2003. The IMR of Maharashtra is 42, which means that out of every 1,000 babies born in the State, 42 die before completing one year of life. Between 1996 and 2003 the IMR declined only by six points from 48 to 42. During the same period, the IMR of India declined by 15 points. Maharashtra, with a much better socio-economic status, should be able to do better. In order to achieve the goal of the population policy, the decline in the State needs to be five times faster than the current pace.
The State government has submitted before the High Court that nearly 1,600 child deaths occurred in the tribal areas in the past four months. Is this true?
This is a truth, but a partial truth, only the tip of the iceberg. Although the problem is most acute in tribal areas, child mortality is a State-wide problem. The Child Mortality Evaluation Committee appointed by the State government, under my chairmanship, estimated in 2004 that the total annual number of child deaths in the State could be anywhere between 1,20,000 and 1,75,000. Out of these, nearly 23,000 deaths occur in tribal areas, 82,000 in rural areas and 56,000 in urban slums. The problem is of humongous size.
Then why is the government figure so low?We, the NGOs [non-governmental organisations] working in rural and tribal areas of Maharashtra, have studied and pursued this matter of `hidden child mortality' since 1998. We found that the government functionaries try to solve the problem by not counting it. The higher officers accept such false reports because these paint a rosy picture. The Child Mortality Evaluation Committee discovered some disturbing truths. The real number of child deaths were three to four times the number reported by the State government. Without true figures neither the severity of the problem can be realised, nor any accountability can be sought from anybody. The situation is tragic as well as absurd.
What about malnutrition figures?Malnutrition in children can be measured in various ways. If we use the Indian Academy of Paediatrics' classification, which is used by the ICDS [Integrated Child Development Scheme] Department, and look at the figures only of severe malnutrition (ignoring the huge number of mild and moderate cases of malnutrition, for the time being) the ICDS reports that 0.35 per cent of the children in the State are severely malnourished. The National Nutrition Monitoring Bureau's estimate is 5.4 per cent. By this count, nearly eight lakh children in the State are severely malnourished. The situation about severe malnutrition has been almost unchanged for nearly 15 years.
Why is the focus always on malnutrition and not on child deaths?
The picture of a hungry, wasted, miserable child moves you. Media can highlight it. The child is malnourished, but still alive, hence it can be visited, photographed, seen; whereas a dead child has vanished. It has less [media] `appeal'. Moreover, the only evidence could be in the records - which, as we saw, are grossly wrong. So, for the media, leaders and the public, child mortality is notional. Moreover, malnutrition is associated with food scarcity, poverty, hunger, starvation - all of which are emotive and politically explosive issues. Malnutrition, of course, needs serious attention. But child death is the most tragic culmination of malnutrition. It is an irreversible violation of the right to live. Hence, in my view, child deaths deserve immediate attention.
What is the solution to this?The interdependent problems of malnutrition and child deaths are closely linked to economic and social development, education and the status of women. All these need attention. Evidence the world over points out that the supplementary feeding programme has not succeeded in reducing malnutrition. Doling out food does not reduce malnutrition. However, a faster and more feasible approach to solve, at least partly, both the problems could be the health approach, that is, health literacy. First, give every mother, every family the crucial information about how to preserve the health of the child. Empower the family. Second, because most child deaths occur owing to infections - pneumonia, diarrhoea, malaria, measles - make health care available in each village to prevent and treat these infections. Third, nearly 70 per cent of infant mortality occurs in newborns - in the most vulnerable period of human life. Hence, make simple care available to all newborns in villages and slums.
Is it possible to reduce the IMR by this approach?
A group of global experts has concluded, in the Child Survival Series published in Lancet, that two-thirds of the child deaths can be averted if simple but proven health care solutions are made available. SEARCH conducted a series of field studies in 39 villages in Gadchiroli district. Using the approach of health literacy, newborn care and treatment of infections in children, the IMR in these villages has been reduced from the baseline level of 121 to 27. This is an internationally published and recognised study. We can, and should, save these children.
Why do children continue to die or waste away?
It is a combination of several factors: lack of political will to take decisions and allocate resources; choice of programme strategy; ineffective implementation of the programmes; and, most important, in the government system, accountability. Nobody is accountable today for the failure of government programmes. The departments hide their failure by making it impossible to seek accountability. That is why there is so much reluctance even to count correctly child deaths and causes of malnutrition. There is a need for social audit of child mortality and malnutrition. The Union Finance Minister is talking about performance accountability. That is very necessary.
Is the committee under your chairmanship doing something to enforce such accountability?
The committee discovered some disturbing truths. We have suggested a series of solutions in the two reports. The government has announced in the State Legislature that it will implement the major recommendations of the committee. When and how the government does that needs to be observed and monitored. The committee, with its job done, has been dissolved. Who will monitor and seek accountability from the State government? The High Court has suo motu initiated a PIL on the issue of malnutrition and child deaths. The court is seriously concerned with the issue. Hopefully, it will seek and enforce accountability.
