Tens of thousands of children die every year in Maharashtra, mostly in the tribal areas, because of malnutrition-related problems. The State government, relying on incomplete data collected by its agencies, refuses to admit the reality and act.
LYLA BAVADAM in Thane and MumbaiLAST YEAR, in what seemed like a crusade to awaken the conscience of the Maharashtra government, the Marathi-language press relentlessly published reports on the continuing deaths of large number of children owing to malnutrition. The reports said that between May and April 2004, as many as 234 children had died in Nandurbar and Dhule districts, 2,000 in the five tribal-dominated districts of Amravati, Yavatmal, Gadchiroli, Chandrapur and Bhandara in the Vidarbha region and 72 in Dharni and Chikaldhara taluks in the Melghat region, and that 600 children were afflicted with Grade 4 malnutrition, which is life-threatening.
The distressing statistics and photographs had the desired effect. Chief Justice Dalveer Bhandari and Justice Dhananjay Chandrachud of the BombayHigh Court were spurred into action and suo motu writ petition No.5629 of 2004 was born. A notice was issued to the State government, bringing the issue of malnutrition-related deaths and other causes of infant mortality to the forefront once again.
In July 2004, the court issued the first set of directives to the government seeking immediate action. The government was directed to provide the factual health status in representative villages in Gadchiroli, Yavatmal, Amravati, Nandurbar and Dhule districts. The findings in the status report were depressing, but predictable. They brought up the issue of inadequate medical facilities and chronic under nourishment among children for discussion yet again. The State government set up the Committee to Evaluate Child Mortality, headed by the community health specialist Dr. Abhay Bang of the Society for Education, Action and Research in Community Health (SEARCH), whose 2001 report in Marathi on child deaths (Kowali Pangal, or The Fall of Tender Leaves) had also been instrumental in the suo motu action by the court.
In August 2004, the committee submitted its first report, which highlighted the magnitude of the problem and the under-reporting of child deaths by the government. The 55-page report estimated that between 1.20 lakh and 1.75 lakh children died every year in the State for medical reasons. It warned that 38 lakh children would die in the next 20 years if the authorities remained "insensitive to their sufferings". The report blamed an insensitive bureaucracy for the plight of nearly eight lakh children whose lives were threatened by Grade 3 or 4 malnutrition.
Reviewing the 15-year record of the State in this matter, the report said it found little improvement. The percentage of children affected by Grade 3 or 4 malnutrition had fallen by a mere 0.6 per cent between 1988 and 2002. It also quoted from a study of the National Nutrition Monitoring Bureau (NNMB), which said that more than 40 lakh children were affected with Grade 2 to 4 malnutrition in Maharashtra. It estimated that 82,000 children died every year in the rural areas of the State, 23,500 in the tribal areas and 56,000 in urban slums.
Although the report was tabled in the Legislative Council in December 2004 and the Health Minister accepted it saying that its recommendations would be implemented, not much has happened. In March 2005, the committee presented its second report. This report took the next logical step of making detailed recommendations on how to reduce malnutrition and child deaths.
In July, showing continued interest in the matter, the court followed up the case and inquired what the State government had done. The government admitted that this year there were 1,600 deaths of children. However, this figure in no way gives the real picture as it only gives the number of child deaths in the five tribal-dominated districts, recorded over a period of five months.
According to government statistics, the total number of child deaths in the entire State between July 2004 (when the court took an interest in the matter) and June 2005 is estimated to be 45,000. Interestingly, the estimate based on the Sample Registration Survey of the Government of India for the same period is 1,20,000 deaths.
On September 16, the court directed the State government to submit a time-bound programme to implement the recommendations of the committee.
The court case has indeed succeeded in bringing out the crux of the issue. The State government was guilty of two things - inability to check malnutrition-related deaths and inaccurate maintenance of records of the death of children for various medical reasons, not just malnutrition.
There are two issues that need to be tackled on a war-footing to reduce the high rate of child mortality. One is, of course, immediate medical relief for children afflicted by malnutrition and the prevention of further cases. The second is to ensure that there is accurate collection of data by the State on child deaths from all medical causes. After the public outrage that followed the 2001 publication of Kowali Pangal, the State government promised that there would be 100 per cent reporting of child deaths. However, no significant improvement has been made since then.
In order to rectify this situation, the committee suggested an action plan, which is as follows: Reiterate the clear goal of reducing the Infant Mortality Rate (IMR) to 15 per 1,000 live births by 2010, which is the aim of the State's Population Policy of 2000 take a decision on fixing accountability - follow a model where the Health Department, the administrative services and the political leadership all share responsibility - and enforce it; give the highest priority to the issue and allocate resources; follow the detailed set of programme recommendations made to the Health and Integrated Child Development Services Department; have a reliable mechanism to monitor the IMR; and present the status report annually in the State legislature and before the High Court.
THE struggle to make the State accountable has a long history. The problem of under-reporting child deaths was discovered in Gadchiroli, one of the State's least developed districts, almost a decade ago by SEARCH. The organisation runs a vital statistics measurement system in about 100 villages in the district. In 1998, its team noticed a huge discrepancy between its own findings and those reported by the Health Department. The matter was taken up with the Chief Minister, and the District Collector was asked to re-check the facts. Although an entirely new set of figures emerged from the Collector's report, it did ultimately validate SEARCH's findings. The Health and Family Welfare Department had said that the still-birth rate was four. The Collector's report found it to be 68. The Department claimed an IMR of 13. The Collector found it to be 118.
The differences were shocking and the Health Department stood exposed. The government reacted by transferring the Collector. SEARCH, however, kept up the pressure and with 13 other non-governmental organisations (NGOs) formed the Child Death Study and Action Group (CDSAG), which studied births and deaths in 226 villages and six urban slums for two years at 13 different sites in the State. There were two major facts that the study brought out:
1. While the IMR for the State was a high 66, it was highest in the tribal areas, at 80.
2. The government was severely under-reporting deaths - in 1998 there were an estimated 1,75,000 child deaths but only 30,000 were officially recorded. This happened apparently with the knowledge of local officials.
Why is it important for the administration to show, statistically, a lower number of child deaths? A district's annual plan is based on the feedback of the previous year. It follows that if the data indicate a reduction in child deaths, that will be seen as a success story for the district administration. However, if the field data indicate a rise in child deaths, it would be seen as a reflection on the inefficiency of the field workers and the department. Thus, by presenting inaccurate data the administration was trying to avoid the problem. This kind of evasion naturally perpetuates the problem. If the records are inaccurate, how can the services be effective? With medical services, not easily available, especially in remote areas, the gap between the number of reported deaths and actual deaths increased. The CDSAG study showed that only 30 per cent of the actual infant deaths were reported in the Management Information System (MIS).
The CDSAG study found that neo-natal deaths accounted for 58.7 per cent of the child deaths, pneumonia for 13.2 per cent, malnutrition 10.4 per cent, and diarrhoeal diseases 10.1 per cent. The remaining 14.3 per cent were attributed to unknown causes. Despite their relatively low percentage, malnutrition-related deaths invariably get more public attention. Bang says, "Malnutrition involves food, hunger and poverty making it not just a medical issue but an emotive and political one as well. The availability and distribution of food are political issues and are directly related to malnutrition, making hunger or malnutrition deaths almost exclusively a political issue. Malnutrition is difficult to prevent because you need wider political policies that encompass issues of livelihood, employment, socio-cultural understanding. Health interventions, on the other hand, are easier to put into action and can bring down child mortality rates. We have been trying to bring this to the notice of the government."
Health interventions are easier to implement and have the desired effect in a quicker time-frame and since it is the disease that ultimately kills a malnourished child, prevention of disease is as important in the fight against child mortality as is eradication of malnutrition. Thus, a two-pronged attack is required to minimise child deaths.
Global experts estimate that two-thirds of child deaths can be averted by simple health interventions. Proof of this comes from what SEARCH has achieved in Gadchiroli, a district associated with poverty and under-development. In a field-based trial, Bang first treated pneumonia in children and brought down the IMR from 121 to 79 in two years. Thereafter, the IMR remained steady despite further reduction in pneumonia and diarrhoea cases. It was only in1990 that Bang realised that 75 per cent of the dead were newborn children.
Three years later, the internationally acclaimed field trial by SEARCH began in Gadchiroli. It showed that an approach called Home-based Newborn Care could make a huge difference to babies, living or dying. The basis of the programme was an understanding of the region and of tribal culture. SEARCH was aware of the tribal belief that a pregnant mother must starve herself so that the foetus remained small and enabled easy delivery of the baby. Working with these cultural constraints, SEARCH trained village women and dais (midwives) in maternal and neo-natal care. Simplicity was the keyword and emphasis was laid on safety, education and eradication of harmful superstition.
The approach was so successful that the IMR of Gadchiroli was bought down from 121 to 30 per 1,000 births, almost equal to that of China, which has made rapid strides in bringing down the IMR. SEARCH also developed the Arogya Swarajya health care model. As the name suggests, this involves a self-management of health aimed at reducing child mortality. It is a decentralised model that provides knowledge and information on health, basic diagnostic skills and treatment as well as basic medicines and equipment.
Although statistically child mortality is a Statewide problem, it is more acute in the tribal areas. Deaths of tribal children account for about 1/8th of the total child deaths in the State. That tribal areas need special attention is apparent from their high IMR of 80 as compared to 64 in the rural areas and 68 in the urban slums. Owing to their remoteness, many medical centres in the tribal regions are often seriously understaffed. A senior doctor in a cottage hospital in the tribal area of Thane district said, "Medical staff do not want rural postings because they are seen as dumping grounds. We do not mind working here as long as there is some assurance that we will be relieved after a certain period."
The Jawhar cottage hospital has 54 beds but it caters to more than 100 in-patients. It functions with a staff of six doctors and 15 nurses when it should have seven doctors and 17 nurses. It is soon to become a subdivisional hospital with an official sanction of 100 beds. Its official staff complement should rise to one medical superintendent, 13 medical officers and 34 nurses.
The neighbouring Vikramgadh taluk, where malnutrition is common, lags far behind in respect of medical facilities. When Frontline visited the six-bed Vikramgadh Primary Health Centre three years ago, the local administration had said a cottage hospital was soon to be built there. The plan is still only on paper. Meanwhile, this year's cases of 43 children affected by Grade 3 and 4 of malnutrition in the taluk could not be hospitalised because of the lack of space. In the past three months 20 children have died in Vikramgadh.
The government is also urged to keep in mind cultural sensitivities while treating tribal people. The harsh realities faced by tribal parents have to be incorporated into the care-taking. "Small things like an irregular bus service affects them - if they cannot get back to their village by night they have to wait all night, without food, at the bus station. The problem is definitely because of poverty," said a medical officer at the Vikramgadh PHC. The inability to afford the bus fare to the PHC, to feed a child every two hours as directed by the doctor, to leave fields untended or, as in the case of agricultural labour, to be absent from work are all factors that affect tribal health. Other, simpler issues such as the use of beds also need to be considered. While caring for her two-year-old child, a mother in the Jawhar cottage hospital prefers to rig up a hammock under the bed for her child. She herself sleeps on the floor. The bed with its white sheet remains unused.
Poverty is at the root of the problem and only sensitive field workers understand the depth it has reached. In order to counter malnutrition, the government gives a high-protein diet of khichadi (consisting of lentils and vegetables) to tribal children in Thane district. Most children take the khichadi home and share it with their large families. That a family of five or more depends on food meant for one exposes a dimension to the poverty that was clearly not anticipated when the government decided to give free food. When a child is hospitalised, it automatically means that the mother cannot earn for that period. This means a vital loss to the family's already meagre income. In an effort to counter this, the government gives Rs.40 a day to the family while the child undergoes treatment. While the link between employment, livelihood and health has been accepted this has not been factored in appropriately in working out counter-measures.
According to Arun Bhatia, who retired from the Indian Administrative Service as the Commissioner of the Tribal Research and Training Institute in Pune, the problem is not a medical one but one of economics. Bhatia had written a report on "Malnutrition-related deaths of tribal children". He believes in "increasing the purchasing power of tribals [to see] a dramatic change in their health status". This is only too apparent in areas such as Thane where tribal people depend on agriculture for their livelihood. There is almost a direct correlation between malnutrition-related deaths and the monsoon. If the rains are timely and plentiful, there are fewer malnourished children. But, as happened in 2002, when the monsoon was delayed there was a high incidence of fatality among children. The majority of tribal families in Thane are landless. Those that do own land hold less than 0.8 hectare. Food shortage is common and people rely heavily on the Employment Guarantee Scheme (EGS) for work and money.
But the existence of poverty and malnutrition is evidence that the existing EGS works are not answering all the needs. Modifications to the EGS are desperately needed because they can be the most effective counter to the exploitation of the agricultural labourer, who is caught between a highly exploitative rent for tenanted land - he hands over 50 per cent of the produce - and an EGS wage that is lower than the agricultural wage.
Furthermore, powerful landlords also contrive to prevent any EGS works being implemented in their area so as to maintain their regular supply of poorly paid labourers. In his report, Bhatia writes, "Unless these distortions are recognised, the same defective analysis will be employed to conceal the ugly picture of absolute poverty and malnutrition deaths and the same solutions will be applied regardless of their relevance or efficacy." Bhatia and his team set out policy recommendations in the report. To date, none has been implemented.
In the context of employment and health, the National Rural Employment Guarantee Scheme could literally turn the situation around. Furthermore, its emphasis on female employment is particularly relevant since studies such as the National Family Health Survey II show that malnutrition in children is linked to the mother's health status. The survey also emphasises how important the earnings of a woman are, both for her family and for her own social and health status.
A RECENT report of the Punarvasan Sangharsh Samiti (PSS), a group that fights for tribal rights, says, "The root [of malnutrition] is because of deprivation from natural resources." In a survey carried out in 22 villages and two resettlement sites of the Sardar Sarovar Project in Nandurbar district, the PSS found that more than 98 children died in April, May and June this year, and 71 of the deaths were related to malnutrition. The survey also verified what the Committee to Evaluate Child Mortality had said: That the government only records 10 per cent of the actual deaths and that malnourishment is rampant among tribal mothers as well.
The other north Maharashtra region to be afflicted with malnutrition is Melghat. The problem is so pernicious here that the government came up with what was thought of as a solution and came to be referred to as the Melghat pattern. Essentially, this involved pumping in a lot of money prior to the monsoon. It was not particularly successful in addressing the problem. The case in north Maharashtra is complicated by the existence of vast forest tracts and, in Melghat, by the presence of large nature reserves, which have been the target of ire of tribal rights groups. Unfortunately, while attempting to do their best for the causes they espouse, both conservationists and tribal rights activists have been at loggerheads. It is only recently that a new direction has been given to resolve the problem. The basis of the new understanding between the two groups is that forced relocation of tribal villages is not the solution.
In an interaction that started in 1998, both tribal rights groups and conservationists found they had common ideas. Neither wanted major tarred roads within the forest; instead they showed preference for small approach paths through the jungle. Neither wanted huge development projects or even major infrastructure such as huge hospitals and schools inside the forest. Surprising as this may sound, the argument has a firm basis. First of all, the objections were not to development per se but to major development works within the forest. Past experience has invariably shown that major development and infrastructure projects taken up within forests under the guise of tribal welfare have merely been an excuse to take over ultimately the land for creating luxury resorts and private holiday homes.
In the Melghat region itself there have been examples in the past of tribal people being ousted from their land because developers claimed that they had been paid for it. The tribal families ultimately crossed the border and settled in urban slums in Madhya Pradesh. In the new interactions between tribal rights NGOs and conservationists, the focus is on facilitating livelihood earnings and self-determination and not on edging out the tribal people.
Simultaneously, the health care needs of the tribal people in Melghat are being addressed. A mobile health unit started by the Nature Conservation Society Amravati holds regular health camps in remote hamlets. The patients are all tribal people and a variety of ailments from malnutrition to bronchial asthma are treated. Recently, even emergency surgery was performed on an 11-year-old boy who had a life-threatening hernia. Treatment, medicines and clothes are provided free of cost to the patients. More than 1,000 patients were treated between June and August this year in regions where government health care did not penetrate.
While much has been done at the ground level by NGOs and sometimes by the local administration, the government has made no comprehensive changes in its approach. After a light rap from the High Court last year over the mounting infant deaths, the State government went into what is referred to as "mission mode" to tackle the problem. It initiated the Malnutrition Eradication Mission. Started in Thane, Nandurbar, Amravati, Dhule and Gadchiroli districts, the mission was meant to follow nutritional guidelines based on a child's age. With the Chief Minister at its head, it was planned on the same lines as the polio eradication and literacy campaigns. Not much is heard of the mission now. NGO reports, departmental crusades and even court interventions have all raised an uproar at various points. In 1997, the Nagpur Bench of the High Court issued directions on three different petitions on malnutrition pertaining to the Melghat region. The State government has not implemented the court orders in full. The main problem, as Bang has been persistently pointing out, is one of accountability.
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