Dying young

A malnourished child being weighed at Nandurbar in Maharashtra. A file picture.-VIVEK BENDRE

LAST 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 April and May 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 Bombay High Court were spurred into action and the 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 undernourishment 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. 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, the court inquired what the State government had done. The government admitted that this year there were 1,600 deaths of children.

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.

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 States 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 recheck the facts. Although an entirely new set of figures emerged from the Collectors report, it did ultimately validate SEARCHs findings. The Health and Family Welfare Department had said that the still-birth rate was four. The Collectors report found it to be 68. The Department claimed an IMR [infant mortality rate] 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 the 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. The CDSAG study found that neonatal 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.

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. 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 in 1990 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 neonatal care.

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.

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.

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.

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 childs 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.