Cover Story

Hunger and hard facts

Print edition : November 11, 2016

A malnourished child from Sheopur in Madhya Pradesh, in a hospital on September 18. Photo: A. M. Faruqui

Parents return with  their child’s body from the district hospital in Malkangiri district in Odisha, on October 8. Several children in the tribal belt are at risk because of Japanese encephalitis and malnutrition-related illnesses. Photo: Biswaranjan Rout

At Bhospada village, 40 km from Mokhada town in Maharashtra's Palghar district, residents carry a sick child to hospital. The district reported 208 malnutrition-related deaths between April and August. Photo: Prashant Nakwe

In the latest Global Hunger Index, India is bracketed in the category of countries where hunger levels are “serious”. But the policy responses on hunger and malnutrition in the country have been inadequate and faulty.

In the second week of October, a few media reports in India highlighted significant data pertaining to global hunger. The International Food Policy Research Institute (IFPRI) had released its Global Hunger Index (GHI), rating 118 countries based on four components—under-nourishment, child wasting, child stunting and child mortality. The higher the score the higher were the levels of hunger. India was ranked 97 on the list of 118, worse than its neighbours Nepal, Bangladesh and Sri Lanka, but marginally better than Pakistan. According to the report, the levels of hunger are marked from serious to alarming; India was bracketed in the category of countries where hunger levels are “serious”. Strangely, there were no reactions from the government. The GHI hunger reports came at a time when news of malnutrition deaths in Palghar in Maharashtra, Jajpur in Odisha and Sheopur in Madhya Pradesh began appearing in the media.

Fortuitously coinciding with the release of the hunger index was a two-day national consultation on food fortification, held in New Delhi on October 16 and 17, jointly organised by at least four government departments and overshadowed by several private partners, including food business operators and their associations. The consultation resolved to “commit to collaborate with food manufacturers, businesses and scientists to utilise efficient technologies in all phases of processing, production, packaging and transportation for promoting safe and nutritious fortified foods and generate awareness regarding its benefits amongst consumers”. In short, food fortification was seen as a crucial component to tackle food and nutrition security as well as child malnutrition. Recognising that staple foods that were produced, procured and consumed in the organised sector were not easily amenable to fortification, the stakeholders urged the government to mandate the use of fortifiable commodities in all its food-based schemes, including the midday meal scheme in schools, the Integrated Child Development Services (ICDS) and the public distribution system (PDS).

But not everyone thought that way. It was pointed out at least by some that there was more to tackling malnutrition than fortification and that a time frame was unreasonable to suggest. Issues of supply of basic unfortified staple food through government schemes were clearly not high on the agenda of the consultation. In any event, there was little consensus on who would bear the costs of fortification, however minimal. The focus of the consultation was on micronutrient deficiency and not on nutritional deficiency as a consequence of insufficient food intake.

Meanwhile, on October 20, Minister for Women and Child Development Maneka Gandhi, while inaugurating three anganwadi centres in her constituency, Pilibhit in Uttar Pradesh, said that the government had signed an agreement with Vedanta to open 4,000 new anganwadi centres providing state-of-the-art services across the country. This was the first time that an announcement of this scale had been made.

According to a press release, the company would construct 4,000 model new-age anganwadis (ICDS centres), called Nandghar, in the country. The Union Minister described it as a unique public-private partnership in the social sector. The chairman of Vedanta, describing it as a game changer for poverty alleviation, said that the Nandghar project “aligns with the government’s vision and commitment to providing quality education for children and job creation through skill development for women, across the country”.

The issue of whether Indians were eating adequate food at all or not has been routinely sidestepped. In recent times, sanitation rather than availability of food has been increasingly gaining traction as one of the reasons for malnutrition and undernutrition. The emphasis on toilets and handwashing has followed from this understanding. Similarly, the supply of ready-to-eat foods and food mixes given through ICDS centres has been replacing locally procured and prepared food for children under five, pregnant women and lactating mothers. The government’s response to this has not been holistic in any manner.

Council for nutritional challenges

In 2008, the government constituted the Prime Minister’s Council on India’s Nutritional Challenges under the Prime Minister’s Office (PMO); it met only once. It was supposed to give a quarterly report to the PMO on the nutritional status in the country. A huge campaign involving film stars and political representatives to combat malnutrition was launched, but there have been no progress reports or any further meetings of the high-powered council. The council itself has not been reconstituted despite written inquiries by its members. Arun Gupta, a paediatrician working on public health and nutrition who was a member of this council, told Frontline that he no longer had his designation as a member of the council printed on his visiting card. “The council has not been dissolved, neither has it been constituted,” he said. Moreover, last year, the Bharatiya Janata Party-led National Democratic Alliance government did away with the four-decade-old National Nutrition Monitoring Bureau (NNMB), which brought out nutrition monitoring reports. The NNMB was established in 1972 by the Indian Council of Medical Research (ICMR) with a central reference laboratory under the National Institute of Nutrition (NIN), Hyderabad. The bureau had a presence in 10 States where trained investigators collected data on nutritional status from a representative population. The National Nutrition Policy of 1993 underscores the importance of nutritional surveillance. It says: “The paucity of reliable and comparable data from all parts of the country is a definite obstacle towards a realistic and disaggregated problem definition. This calls for a nationwide monitoring system. To achieve this, it is necessary to restructure and strengthen the existing NNMB and to develop a mechanism for generating nationwide disaggregated data.”

Its surveys on the trends of dietary intakes and patterns of consumption were, therefore, crucial to an understanding of what India was eating, especially the vulnerable sections of the population. After all, this was a prerequisite for policy interventions on nutrition. Apparently, the government did not want any more project-based surveys. It is unclear as to what would happen to those who were employed under the bureau in its State units. Informed sources told Frontline that the huge volume of data generated from the NNMB were never utilised for policy. The winding up of the bureau would affect policy in the future.

The NNMB had been carrying out diet and nutrition surveys since 1975-79 and did repeat surveys in 1989-90, 1996-97 and 2011-12. For instance, it carried out four rounds of diet and nutrition surveys in the rural population with an average interval of 10 years between 1975-79 and 2011-12. Similarly, three national-level diet and nutrition surveys were conducted among tribal populations with an average interval of 10 years between 1985-87 and 2007-08. A 1983 NNMB survey was linked to the consumer expenditure survey conducted by the National Sample Survey Office (NSSO) and explored the link between per capita expenditure and consumption data. The analysis of this and another in 2014-16 was in progress.

According to information that was sought from the NIN, the surveys of the NNMB revealed that the intake of all foodstuffs, except pulses, vegetables, fats and oils, had declined over a period of four decades. The intake of micronutrients, excepting Vitamin A and C, too had declined in the same period. The latest survey conducted in 2011-12 among 11,910 rural households showed that there was a deficit in the recommended daily allowance, or RDA, for all foodstuffs such as cereals, millets, pulses and legumes, green leafy vegetables, other vegetables, milk and milk products, fats and oil, and sugar and jaggery. The only item that was consumed in excess over the RDA was in the category of roots and tubers. The deficit was particular in milk and milk products, green leafy vegetables and sugar and jaggery. Jaggery is known to be a natural source of iron.

The prevalence of undernutrition and hunger among the vulnerable sections of the Indian population was among the highest in the world. And dietary inadequacy, explained a nutrition officer at the NIN, was one of the most important factors for undernutrition and hidden hunger. In response to specific queries on food intake, Frontline learnt that the intake of cereals and millets had declined by 137 grams a day over four decades. A similar trend was observed in the case of roots and tubers, milk and milk products and other vegetables. The decline of protein was 13 grams a day. There was also a significant decline in the intake of micronutrients such as iron, thiamine and riboflavin. The average intake of energy declined by 500 kilo calories per consumer unit a day in the same period. India, clearly, was not eating enough.

“Malnutrition is one of the biggest problems but not the only problem. There is undernutrition and problems of overweight and diabetes too. A public health nutrition centre will be set up within the NIN. In addition to collecting data, we need to focus on data on how to inform policy. To have an impact at the population level, there has to be a policy. Whether [it is on the] introduction of millets in the PDS, salt labelling on foods, tax on sugary foods or even fortification, we need a policy. We have set up sub groups on Vitamin A, Vitamin D and to understand why our iron folic acid programme has not been successful. For instance, why do we have poor iron absorption, etc., needs to be studied,” ICMR Director General Soumya Swaminathan told Frontline.

Experts say there apparently seems to be a link between intestinal infections and absorbing capacities of supplementary nutrients in the gut. “If one is eating a wholesome diet, then there is no need for any fortified or supplementary food,” said Soumya Swaminathan. She said that millets had become a food item in the households of the rich while the poor, especially the tribal people, who used to eat millets and other coarse grains, were now consuming white rice. A policy on nutrition, she said, should be able to address these issues as well.

Child health, especially in the under-five category, is one of the parameters used to compute the GHI because children are viewed as “an important subset of the population for whom a lack of dietary energy, protein or micronutrients (essential vitamins and minerals) leads to a high risk of illness, poor physical and cognitive development or death”. Malnutrition among children in this age cohort therefore becomes significant. But there have been legitimate doubts over the degree of severe acute malnutrition and the solutions that are being offered to combat it.

In August last year, a group of nutritionists and paediatricians pointed out in a note to the Prime Minister that severe acute malnutrition, or SAM, was overstated and used as an excuse to push ready-to-eat food in the form of industrially manufactured products. They said there was evidence of decline of such malnutrition whereas the majority of under-five deaths occurred within six months after childbirth where supplementary nutrition was irrelevant. The signatories to the note pointed out the need for quality food security to all as well as preventive and optimal curative health care instead of targeted interventions involving specific categories of children and industrially manufactured food.

Their concerns were not misplaced. Over the past few years, there have been attempts to offer product-based solutions in the form of ready-to-use therapeutic food (RUTF) to combat severe acute malnutrition. Clearly, such food was to be prepared in collaboration with industry. Some States have also introduced such food for breastfed children. In Gujarat this year, in the form of a pilot project, 50,000 children in 13 tribal districts were identified as severely malnourished and were to be the recipients of therapeutic supplementary food called Balamul, prepared by Amul.

Weak delivery of services

Even where it was being offered as an alternative to food locally produced and prepared in ICDS centres, the response among the beneficiary cohort was weak, said office-bearers of ICDS worker associations and unions. They are also concerned about the consistent neglect of their demands relating to the functioning of a robust ICDS scheme. Sabita Mullick, president of the ICDS Supervisors’ Welfare Association in Haryana, was suspended from work when the association gave notice for a one-day protest on October 21 on several work-related issues.

Several supervisor posts, she said, were lying vacant all over the State and the government had not made any appointments citing cash crunch. It was a fact that ICDS budgets were slashed by the Central government this year. The existing supervisors were overburdened with work with the launch of every new government scheme at the Centre.

Sabita Mullick said 300 supervisors from all over the State were expected to join in the protest. “We have been asked to submit online reports. Where are the computers? We have to spend money from our own pockets. We asked the government to give us a data entry operator. How can malnutrition be addressed with this kind of an approach? The government wants to reduce the figures of the malnourished without addressing the reasons why it is so in the first place,” she said.

Supervisors were required to mark biometric attendance at the nearest school, college or hospital. Sabita Mullick said that supervisors were field workers; it was unrealistic to ask them to mark attendance as a lot of time was wasted in locating a facility, apart from the fact that women did not feel secure in such environments.

Each supervisor deals with 25 ICDS centres. Giving details of the shortfall in the staff, she said that in Palwal district, against 39 posts of supervisors, there were only 11. In Mewat, one of the most backward districts, there were only 11 supervisors against 47 posts; in Faridabad district, 27 posts of supervisors were lying vacant.

Similarly, there is a shortfall of statistical assistants and accountants. The statistical assistants were supposed to compute the data on nutrition. “Supervisors are supposed to do all this work in addition to getting involved in various campaigns of the government like ‘save the girl child’ or building of toilets. Of late, we also have to organise ceremonies around the birth of a girl child in the State. They told us to make Aadhaar cards as well in addition to all this. We declined and so have been suspended,” Sabita Mullick told Frontline. The staff was also pressured to show that levels of hunger and malnutrition were low. Reporting of malnutrition and other parameters, therefore, was weak, she said.

Other problems include rations never arriving on time and those that did being unsuitable to local tastes. In Haryana, for instance, soyabean, which is not part of the local diet, is used in ICDS centres. The supply of fuel is erratic, with the result that workers have to pay for it.

Salaries of all categories in the ICDS have been erratic, with non-payment stretching for months together. “If the government was really interested in tackling malnutrition, it would address these issues as well. Yes, there is a lot of stunting among children. People do not get to eat enough at home. A supplementary is a supplementary after all.

Besides, if salaries do not come on time, the workers will look at the rations as an alternative to supplement their needs. The corruption starts from the top, but the workers are blamed for everything,” she said.

Similarly, in Uttar Pradesh, ICDS workers launched a protest on October 21 demanding basic infrastructure at the centres and the implementation of an agreement with the Labour Commissioner regarding minimum wages.

Veena Gupta, president of the Anganwadi Workers Union, told Frontline that there were no serving utensils in the centres. “The women are told to bring plates from home. They find it humiliating. There has to be respect for people,” she said, adding that the government had entrusted a contractor with procuring raw materials. In Madhya Pradesh, where around two dozen malnutrition deaths had occurred in Sheopur district, it is a similar story of neglect. Kishori Varma, the secretary of the State Anganwadi Federation, told Frontline that the ready-to-eat food was rejected by the beneficiaries. “They sold it as fodder. Malnutrition starts from home. People are eating salt and rice as part of their daily diets. It can be addressed if there is proper employment. There is pressure on the ICDS worker to show good performance reports,” said Kishori Varma.

The ICDS is the largest nutrition scheme in the world run by a government for children, pregnant women and lactating mothers. It is the largest food supplementation programme in the world and the midday meal scheme is the largest school meal programme in the world. A supplementary nutrition scheme for the poor, the ICDS has now become the new catchword for addressing issues of malnutrition and undernutrition. But government investment in either the scheme or its linchpins—ICDS workers and helpers—has been found wanting. The workers are not recognised as government employees even though there is hardly a single government scheme where they are not involved.

Hunger levels cannot come down by quick-fix solutions or a myopic approach to nutrition and health. The budgetary cuts in ICDS and other food-related schemes, apart from economic distress among the most vulnerable populations will only compound the problem. It is the availability of food, in any form, that is the challenge at present.