A story of neglect

The Maharashtra government plays down the significance of the death of some 22 children rendered vulnerable by malnutrition, in the predominantly tribal Thane district.

OVER the last five months, 22 children, between the ages of six months and three years, are reported to have died in the tribal belt of Wada taluk in Maharashtra's Thane district. The listed causes are as varied as tuberculosis and pneumonia and meningitis and kidney failure. However, the reality has been exposed. What emerges is a story of neglect and a situation that is far more serious than is being portrayed by the State government. Severe malnutrition had left the children vulnerable to diseases. Non-governmental organisations (NGOs) working in the district said that malnutrition was a chronic condition among the tribal people. Investigations reveal that instances of many more deaths remain unreported and several cases have not been diagnosed.

At a Primary Health Centre (PHC) in Vikramgadh taluk, a board in the medical officer's room lists 37 children as suffering from Grade III malnutrition and 11 as suffering from Grade IV malnutrition. Five are listed under the heading `deaths by malnutrition'. These five unidentified children were between one and one and a half years and at the time of their death weighed less than 2 kg. The normal weight of children in this age group is about 5 kg. The Rural Hospital in Jawhar has 12 Grade IV cases and 11 Grade III cases. A medical officer in a PHC remarked: ``You can imagine the number of cases in the villages that are Grade I and II and are currently undiagnosed.''

The type of malnutrition that has affected tribal children in Thane district is called PEM, or protein energy malnutrition. The management of PEM involves a high-protein diet of khichdi made from pulses, along with a branded high-protein product. Symptoms of PEM include muscular dystrophy, where the arms and legs become stick-like and are unable to bear the individual's body weight, a distended belly and physical exhaustion. Over a period of time the body's immune system wears out, leaving the patient open to ailments such as TB, pneumonia and kidney infections which, if left untreated, could result in death.

Diagnostically, malnutrition cases are divided into four grades. Grade I, or mild malnutrition, occurs when the body weight of the person is between 70 and 80 per cent of the expected weight for that age. In Grade II, representing moderate malnutrition, the body weight is between 60 and 70 per cent of the average. Both Grade III, where an individual's body weight is 50 to 60 per cent of the average weight in a particular age-group, and Grade IV, where the body weight is 50 per cent of the average, are referred to as stages of severe malnutrition. In Thane, all the cases that have been brought to the attention of the authorities belong to Grades III and IV.

On paper, the medical infrastructure seems to be well planned. Every village and pada (hamlet) has an anganwadi worker who has a basic level of medical training. The worker is responsible for reporting the health status of the area to the sub-centre or the PHC which, in turn, reports it to the Rural (or cottage) Hospital in the taluk headquarters. The district hospital is at the top of the pyramid.

In reality, anganwadi workers are often lax in fulfilling their duties and cases are frequently misdiagnosed by them. Malnutrition is especially difficult to diagnose by sight unless it is at an advanced stage. The problem is exacerbated by frequent staff shortages.

THE poor state of health care is exemplified by the case of Vikramgadh taluk. Despite having been upgraded as a taluk three years ago, Vikramgadh has no Rural Hospital (although there is a plan to build one). Residents of Vikramgadh still depend on the six-bed PHC. None of the children who died of malnutrition had been hospitalised. They lived in far-flung villages and padas. PHC doctors say that the responsibilities of the anganwadi workers include looking after the children and ensuring that they receive the necessary protein-rich diet. Parents are expected to bring their children in for a regular check-up but, as the medical officer says, this happens only occasionally.

The harsh realities faced by tribal parents have not been taken into account by the government. According to a medical officer at the Vikramgadh PHC, even factors such as irregular bus services affect them. "If they cannot get back to their villages by night, they have to stay at the bus station all night without food. The problem has definitely been created because of poverty.'' Other factors that need to be taken into account are the inability of the tribal people to afford the bus fare, to leave their fields untended or to be absent from work.

Another example from the Rural Hospital in Jawhar shows that the existing system is not responsive to ground realities. Maintaining nutritional levels is crucial to the health and recovery of the child. After a child is discharged from hospital, the parents are given Rs.40 a day. They are also instructed to feed the child every two hours but economic constraints do not permit them to do so. Nurses in the Rural Hospital say that there are a number of ``repeat cases''.

In an attempt to downplay the issue in the wake of a spate of media reports on the malnutrition-related deaths, the government called a press conference in the first week of September. Health Minister Digvijay Khanvilkar, Tribal Welfare Minister Madhukar Pichad and Social Welfare Minister Jayant Awale blamed teenage motherhood, non-institutional delivery of babies, unhygienic living conditions, illiteracy and a preference to consult ``witch-doctors'' for the deaths. They also denied that food and medicine shortages existed in the affected areas and said that malnutrition was not the relevant issue.

The Ministers said that the fault lay with social mores and not with the administration. However, in their attempt to distance themselves from the crisis, the Ministers ended up exposing the inadequacies of the administration even more. Their explanations raised other issues. What was the government doing to prevent child marriages? Why were tribal women not being attended to during childbirth? Was the lack of access to trained medical staff the reason for the tribal people going to ``witch-doctors''?

RESPONDING to the callous statement regarding the availability of food and medicines, among other things, Arun Bhatia, Commissioner, Tribal Research and Training Institute, wrote to the Chief Secretary: ``Kindly understand that these factors do not necessarily justify your conclusion that malnutrition was not the cause of death. A well-stocked jewellery shop in the village does not mean that tribals below the poverty line had diamond earrings. Food stock in fair price shops does not mean that the poor have access to these stocks. It is necessary to assess whether or not the households that sustained the deaths had the purchasing power to obtain foodgrain from the fair price shops. In the absence of this analysis, the mere presence of food stocks in the shops indicates nothing.''

Bhatia drew the Chief Secretary's attention to a report published four months earlier regarding a similar situation in the tribal district of Nandurbar in northern Maharashtra (Frontline, June 7, 2002) where ``it was found that more than 75 per cent of the deaths were malnutrition-related and 57 per cent of the deaths were unreported''. By means of the Nandurbar report, Bhatia demolishes the arguments of the government and points to the nub of the issue. He identifies what he calls the ``three great distortions'' in understanding the problem.

These are, ``confusing the causes of death, ignoring under-reporting of the number of deaths and offering unacceptable employment under EGS.'' (EGS is the government-run Employment Guarantee Scheme.)

Bhatia says: ``To say that the children have not died of malnutrition-related reasons is in itself factually incorrect. How does the government know this? To make a statement like this you have to have been monitoring the children before they died. Quite obviously they were not being monitored, otherwise they would not have reached that extreme state of malnutrition.'' He also casts doubts about the reliability of government statistics in this context, saying that rural staff are so ``under-motivated that we do not know if they are maintaining the records''.

In any case, says Bhatia, the problem is not a medical one but an economic one. ``Increase their purchasing power and there will be dramatic changes in their health status.'' A majority of tribal families in Thane are landless. Those that do own land hold less than three acres (1.2 hectares). Food deficits are common and people rely heavily on the EGS for work and for money. But the existence of poverty and widespread malnutrition is evidence that the EGS is not addressing all their needs.

``We need to listen to the tribals,'' says Bhatia, ``See what they require and listen to their suggestions. Ask the farmer where he wants a dam. Don't impose one on him just for the sake of an EGS project. There is tremendous potential for starting small, relevant EGS works in these areas.'' Bhatia suggests that camping facilities be created for those who are working on EGS projects located far from their homes.

Attention to such matters of detail will increase the effectiveness of the EGS. Bhatia says that the bureaucracy hesitates to implement new EGS projects because ``it is a messy business''. The highly exploitative rate of rent for tenanted land (50 per cent of the produce) is also an indication of the absence of employment opportunities. It is imperative to modify the EGS because it can be the single most effective counter to the exploitation of the agricultural labourer.

EGS wage levels are lower than the agricultural wage and so, given a choice, labourers prefer to opt for agricultural work. However, landowners are capitalising on the situation of surplus labour availability and under-employment by paying even less than the stipulated agricultural wage. Powerful landlords also conspire to prevent EGS works being implemented in their area so as to maintain their regular supply of poorly paid labourers.

Social activists say that in some instances the government has defaulted on payments to EGS contractors and hence finds it difficult to start new schemes in certain areas. This accusation opens a fresh can of worms. EGS works are meant to be operated by the government itself and not contracted out.

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. And, above all, the complacent defence of the status quo will remain unshaken, blocking out new avenues of thought.''

Some of the new avenues suggested by Bhatia and his team are set out as policy recommendations in the report.

One of these relates to agricultural rehabilitation. Here those holding less than one acre of land can be resettled in the command area of irrigation projects once the requirements of the project-affected people are fulfilled.

The proposal fits in with the provisions of the Resettlement Act that says that a land-holding ceiling of 4, 6, or 8 acres can be applied in the command areas of projects to generate land for distribution to project-affected persons. Often owing to pressures from local farmers the 4-acre ceiling norm is not applied. Bhatia justifies such redistribution on the grounds that ``irrigation is heavily subsidised by the state and therefore the benefits of it should be shared on a more egalitarian basis''.

Another recommendation follows from the first one and suggests a resettlement package for tribal people on the distributed land. ``Care should be taken to prepare mentally the tribals for the change... special measures to be taken such as settling them in groups... protecting them from aggression of local farmers... providing separate schools if necessary...''

The distribution of degraded forest land for livestock farming is another recommendation. The suggestion is to give land on long lease to self-help groups consisting of poor tribal farmers. The scheme is expected to regenerate land and provide a source of livelihood to poor farmers. This will require legislation to enable the denotification of reserve forest land.

The provision of monetary and other incentives to staff members working in the rural areas is another recommendation. The report also recommends the provision of mobile banks and mobile clinics.

Participatory planning is another element of the plan. These days ``empowerment through participation'' is the byword in the Mantralaya, the seat of power in the State capital of Mumbai, and Bhatia believes that it will be relevant in targeting poverty and in monitoring the delivery of services.

So far, the government's response to Bhatia's report has been predictable. A committee has been set up, but nothing much has come out of it. There is a proposal to implement what is known as the Melghat pattern, a system that evolved out of the severe and annual malnutrition deaths that occurred in the Melghat area in Amravati district during the monsoon period in 1996 (Frontline, October 4, 1996). The Melghat strategy essentially seems to involve pumping in more funds. Bhatia says he is sceptical about it. He said: ``We need to make a dent in poverty levels. You have to address the core issues that give rise to poverty. Money is not the solution. You need poverty alleviation measures. This is a sensitive subject. You need to handle it with great care.''