Wednesday, April 22, 2009
By Stephanie Nolen From Saturday's Globe and Mail
A complex masala of gender, caste, tradition and politics keeps babies hungry. After 15 years of rapid growth, India has made no progress on childhood malnutrition, unlike many poorer nations. Its culture poses many special obstacles – but that could also be the key to change
DEHDE, INDIA — Devsingh Adivasi has baggy pants. Not literally – in fact, he has no trousers at all – but that's the term for a child like him: At two years old, he has rolls of slack flesh that sag below his buttocks and gather at his ankles, as if his skin was made a few sizes too big.
Devsingh is acutely undernourished. He is less than half the weight or height he should be; he's not able to stand on his own; he is intrigued by the small ball made of reed scraps his mother Papo has rolled for him, but does not have the energy to chase it.
He has never eaten a vegetable and never eaten a fatty food – never, in fact, eaten anything other than the flat bread his mother makes on a cow-dung fire every day or two. He nurses sometimes at her slack breasts; Papo herself, in her late 20s, weighs about a third less than is healthy. She says, softly, that she knows her son gets little milk from her and that she should eat more. “But what would I eat?”
Devsingh is one of six children, all of them malnourished. Each one of the 70 families in this village in the northern Indian state of Madhya Pradesh has a child, or several, in a similar condition. But this is not a blighted place with a unique, horrible problem. What's most horrifying about it is its normalcy, across this state and across northern India.
Canadian parents have been invoking malnourished Indian children for three generations to encourage their own children to eat their crusts or lima beans. In that time, however, India has transformed itself from a land where millions of people died each year in famine to one whose explosive development has won it “emerging superpower” status. In the last 15 years, India's average annual economic growth has been 7 per cent.
It's expected to come close to that mark this year even amid the global economic crisis.
India has a booming information-technology industry, an exploding middle class and cities with sleek subway lines, neighbourhood sushi restaurants and rickshaw drivers who use cellphones. Last year it sent a rocket to the moon. But there is one thing that has not changed – the rate of childhood malnutrition, which still affects one in five children here and causes 3,000 infant deaths each day.
A staggering 40 per cent of undernourished children in the world are Indian; the rate here is twice as high as it is in all of Sub-Saharan Africa and five times higher than in China. The land of the economic boom finishes third-last on Unicef's global list of child nourishment, worse than either Sudan or Ethiopia. In fact, the number of starving children is increasing 2.5 per cent annually, while population growth is barely 1.4 per cent.
India's government itself professes shock that the situation has not improved as the economy has grown. “The problem of malnutrition is a matter of national shame,” Prime Minister Manmohan Singh said last year. There is a growing sense that the scale of the problem does not befit a country claiming superpower status.
“It is embarrassing,” acknowledges Mahesh Arora, who heads the national child-nutrition program through the Ministry of Women and Child Development. “We are trying our level best. You must realize India is a huge country and some areas are doing much better than others.”
Better is a relative term. In the north and east, at least 55 per cent of children are malnourished; in the south it is about 30 per cent. The Adivasi family lives in the worst of the worst areas, and what happens in their house – and what doesn't – does much to explain why the problem persists.
The family has some of the basic problems that plague people around the world, having no land, no assets, no cash to buy food nor any real way to change their situation. As elsewhere, efforts to help the very poor here have been marred by corruption and mismanagement. But these ills are exacerbated by a collection of factors peculiar to India, from a squabble over the philosophical legacy of Mahatma Gandhi to intractable battles over caste hierarchy to the uncommonly stark powerlessness of Indian women.
The Adivasis share their surname, derived from their group in the Hindu caste system, with their whole village. They are what's called a “tribal” group – an indigenous population at the very bottom of the traditional hierarchy. They own no land, and the soil on the land they have been allotted is rocky and infertile and rain is rare. Their village is a jarring hour's drive (not that anyone here owns a vehicle) down a dirt track off a rural road down a lousy highway that leads only to a small town with no industry or opportunity.
No one here in Dehde has a toilet or a source of clean water to wash their hands; they are, like half of all Indians, “open defecators” who walk into the surrounding fields to relieve themselves. Their children run and play surrounded by excrement and as a consequence suffer episodes of life-threatening diarrhea nearly every month.
There is a school in the village, but as in many other parts of India's corrupt and poorly-managed public education system, the underpaid teacher shows up only a few times each month; looking around, it isn't difficult to understand why he might be hopelessly discouraged. There is not a single literate adult in Dehde.
There is a community health worker, 50-year-old Battu Bai, who is paid $36 a month by the central government to weigh the children and keep track of their growth. She enlists a couple of 12-year-olds, the only people here who are numerate, to read the scale and fill in her charts. She is supposed to exhort the mothers of underweight children into proper feeding but, she says, rolling her eyes: “I am hammering them all the time but the men are the decision makers and it doesn't matter what I say.”
Ms. Bai does not have the skills or the resources to treat the diarrhea that claims so many children here each year. She can only refer families to the clinics in the regional capital of Shivpuri, two hours away. But few have money for transport and, she says, the men aren't interested in making the trip and forbid their wives to go alone with sick children.
“Who would cook, or see to the other children?” grumbles Devsingh's father, Prashadi, when Ms. Bai asks him yet again about having his wife Papo take their child to a Unicef emergency-nutrition centre. STUNTED LIVES
In Dehde, poverty is a congenital condition. Papo, who has tawny hair that spills in curls down her back, married Mr. Adivasi when she was 17. She gave birth to their first child a year later. A full 20 per cent of pregnancies in India are in girls between 15 and 19; a quarter of those, like Ms. Adivasi, give birth at intervals of less than 18 months, taking a toll on their own health and leading to weaker babies.
If these children survive infancy, they grow up stunted – no one in the Adivasi family is more than five feet tall. In fact, research by the World Health Organization showed definitively last year that the idea that Asians are inherently shorter than people in the West is nonsense and the disparity is primarily the result of broad, chronic intergenerational malnutrition.
The children are not just stunted physically. They experience delays in cognitive development that can never, at any later point, be repaired. This has consequences for India as a nation: The World Bank says that undernutrition is reducing the country's GDP growth by three per cent each year, as it reduces any individual's lifetime earning potential by at least 10 per cent.
Like Ms. Adivasi, a third of Indian women are themselves underweight. In addition, 59 per cent of pregnant women here are anemic, which means they give birth to low-birth-weight babies with weak immune systems who struggle to breastfeed properly.
In fact, breastfeeding – a free, critical intervention that can make a massive difference in survival past the first month of life – is a fraught part of the nutrition puzzle here. Ms. Adivasi says that she waited until three days after Devsingh was born to nurse her son. For the first two days, which Unicef calls the most critical for determining infant health, she gave him nothing, believing her colostrum (the antibody-rich, yellow liquid new mother's bodies produce before milk) was unhealthy.
Overhearing her recount this, a couple of village men jump into the discussion: “Even an animal would not feed its child with its first milk!” one man says. Another adds, “No woman here would be allowed to give that to a baby.”
India's central government has helpfully put up billboards at the entrance to many of these villages, extolling the virtue of colostrum in lines of Hindi script that, of course, almost no one here can read.
In many places, a father or his mother will consult an astrologer for an auspicious day to start breastfeeding – which could be as many as 30 days after the child's birth. After that, in some families, the babies who survive those first crucial weeks are breastfed for up to three months. But when they begin to fuss, wanting more nutrients than their malnourished mothers can apparently provide, fathers or mothers-in-law often insist that nursing women introduce solid food or buffalo milk, diluted with unclean water – even though babies should be given breast milk exclusively for their first six months.
In other geographic and caste groups, people believe in breastfeeding exclusively far, far past that point – even up to two years. This, too, is nutritionally damaging: After about six months, children need solid food sources of vitamins and nutrients.
“It's not rocket science but it is science,” said Purnima Menon, a researcher with the International Food Policy Research Institute. And no one is explaining it to women such as Ms. Adivasi.
In any case, Dr. Menon added, “Giving information to a young woman alone is not useful if she has such low status that she can't make the decision.” Yet when Mr. Arora, the government nutrition chief, talks about the need for a massive national ad campaign about correct infant and child feeding, he talks always about educating “mothers,” not their husbands or in-laws.
This may be the single greatest cause of India's vicious malnutrition problem: the striking lack of autonomy of women, especially young women and those in rural areas. Today, the Adivasis' grain box is empty – Ms. Adivasi thumps it, scowling at the hollow sound. But when there is grain enough for her to make five chapati flatbreads, her husband eats two, the six children share two and Ms. Adivasi gets one.
When Ms. Bai, the community-health worker, hears this, she reminds Mr. Adivasi that his wife is breastfeeding and needs extra calories. “She gave me two,” he says with a shrug. “I didn't ask what she ate.”
He goes on to describe how he struggles on the 250 rupees (roughly $4.50) that he, his wife and the older children earn each month to buy food and pay the fees for the one son who goes to school. (They do day labour for a national program targeting the very poor.) But after Ms. Bai pulls her sari down over her eyes and adds a loudly muttered observation, Mr. Adivasi acknowledges with a shrug that he spends more than half that monthly income – 150 rupees – on bidi, traditional cigarettes. The revelation startles an outsider, but no one in Dehde seems to find it surprising.
In villages like this one, male children are prioritized from the moment of their conception. “There's a reason why you see so many more boys than girls in the nutrition centres,” says Anne Philpott, an adviser on nutrition to the British international development office in India. From ages 1 to 4, according to Unicef, the mortality rate for Indian girls is 61 per cent higher than it is for boys.
Nothing, notes Dr. Menon, is more core to the function of a family and a society than the way in which it divides responsibility for caring for its children. This is why a state such as Madhya Pradesh, compared with African countries that have similar populations, ranks so badly on malnutrition: Women may in general be oppressed in Ethiopia and Congo as well, but they have autonomy over feeding their children.
“On purchasing food, on feeding herself, on health care – the critical question is how does the gender inequality play out,” says Dr. Menon. “Women in Africa can be out in society at the market, or generating income, buying food for her family. In India women often cannot make those decisions. So here we need to target men as well for purchasing behaviour: Women often don't see the market, so there's no point telling them what to feed.
“And you have to work with older women too if you want to change breastfeeding – because the poor young mother is in no place to argue with her husband or her mother-in-law.”
So entrenched are these patterns – and so normal are listless toddlers such as Devsingh – that nobody here feels they need to react in alarm, says Dr. Vandana Agrawal, nutritional specialist for Unicef in Madhya Pradesh. “A mother sees that her child is weak but she sees that all the children around her are similar so she doesn't perceive a problem and so she doesn't try to address it,” she says.
“She's working in the fields or doing daily wage labour, she gets up and takes care of the whole family, she prepares food and leaves the child with an elder sibling of eight to 10 years old, and nobody takes care of that child in a systematic way.”
Indeed when Ms. Bai tries once again to talk to Prashadi Adivasi about how underweight Devsingh is, he insists there is nothing wrong and simply gets up and walks off while she is speaking.
CASTE-AWAYS Over top of this toxic brew of poverty and sexism is a uniquely Indian complicating factor, the enduring hold of the caste system. Regional child-health workers, and even rural outreach workers such as Ms. Bai, are usually political appointees (the patronage system extends down to the lowest level) and often of a higher caste than the people they serve. As a result, the lowest-caste women are often hesitant to use those services.
In addition, the Adivasi people are considered to be of such low caste that they are barred by custom (not by law, which officially forbids such discrimination) from any of the limited private labour opportunities around their village.
There is a flip side to this situation: Caste organizes Indian society into units down to the smallest community level. Along with the country's long history of mass public action, that should make it easy to do effective public education on behaviour such as breastfeeding.
“If the astrologer is telling women not to breastfeed until 30 days, then get out there and educate the astrologers. Make them your change agents,” says Ms. Philpott, the British nutrition adviser.
With this kind of concerted effort, a great deal can be done quickly: Thailand cut its rate of child undernutrition in half in four years in the 1980s; China cut its by more than half from 1990 to 2002. Vietnam and Brazil have had similar successes. In Malawi in southern Africa – where the economy has not grown at all and the AIDS epidemic has dramatically worsened public health – the government has nevertheless succeeded in cutting the proportion of malnourished children from 30 to 19 per cent in the past decade.
These countries each followed a different approach, but what they had in common were strong government leadership and a combined emphasis on public education, primary health-care delivery and interventions with very poor households. China made an aggressive push to get clean water and sanitation to the poor; Thailand put 20 per cent of the national budget into health care.
India has one major program to tackle undernutrition, called the Integrated Child Development Service. The $1.6-billion initiative began in the 1970s and set up a network of kitchens and feeding centres in rural and urban low-income areas across the country. While it has been praised for its ambition, it is cumbersome and badly managed – “a shambles,” in the off-the-record assessment of one government consultant involved in designing it. Corrupt officials skim the cash, or poorly-trained bureaucrats mismanage the distributions.
“There is no strong monitoring, and there is no accountability of district officials – no sense that ‘I have to serve,'“ says Unicef's homegrown expert Dr. Agrawal, who has watched schemes come and go for years as statistics stay stubbornly unchanged. “I get so frustrated with India,” she adds.
Paradoxically, some of the greatest obstacles are unintended consequences of the work of lobby groups whose members are deeply concerned for the poor. India has a powerful “right to food” lobby, a coalition of charities and civil-rights groups that fought long and hard to extend the Child Development Service to cover all children and for the wage-labour program that employs the Adivasi family for a few days each month. These are widely considered one of the great victories of the powerful leftist political movement here.
Through nearly a decade of litigation, the movement has persuaded the Supreme Court to order the Indian government to take steps such as serving midday meals at all public primary schools and providing grain at highly subsidized prices to millions of destitute households (although far from all). “You cannot overstate the importance of these steps,” says Delhi-based activist Kiran Bhatty.
Yet the very success of this coalition means that the focus of discussion has been on feeding schoolchildren – a debate over whether to provide them with enriched biscuits or a precooked meal dominated the discussion in the national parliament all last year. But the most crucial part of the malnutrition crisis in India has to do with babies, long before their school-aged years. “By the time we're talking about ‘food',” says Anne Philpott, “it's too late.”
INVOKING GANDHI In recent years in Africa, great nutritional gains have been made by providing micronutrient supplements. Giving children Vitamin A at the age of six months, at the cost of a nickel each, can cut child deaths by 25 per cent. But such efforts were derailed in India when a Hindu fundamentalist lobby protested that the capsules were coated in gelatin, a product made of cows, which are sacred in Hinduism. (Today, some areas are having success with liquid Vitamin A drops.) Fortifying widely consumed foods with nutrients such as iron has also been crucial in Africa, and it is desperately needed here, where most people are vegetarian. A stunning 75 per cent of preschool-aged Indians are acutely anemic, according to a national family-health survey. But the anti-corporate left here is highly suspicious. “The anti-business lobby puts an emphasis on products that are locally made and feels that fortification could just be a money-making scheme,” said Dr. Menon.
For example, breastfeeding advocates fear that any discussion about fortifying foods for infants will open the door to formula companies, even though fortification can now be done in the home or a feeding centre, improving an infant's diet without compromising breastfeeding.
Opponents of fortification also frequently invoke the name of India's great independence fighter, Mahatma Gandhi. In his time, he preached the sanctity of the village and said that Indians should sustain themselves on what they grew and produced at that level.
That argument was aimed at trying to lessen British colonial power, but today his self-proclaimed disciples use his words (and little has more power here than invoking “Gandhiji”) to oppose food fortification by saying that whatever is produced in a village should be sufficient.
“There's a perception that surely all of this can be done through food – through natural means, the Gandhian approach – and that the newer approaches are somehow artificial,” said Luc Laviolette, Asia program director for the Micronutrient Initiative, a Canadian program that has worked with the Indian government to boost Vitamin A supplementation here with some marked successes. “The reality is that for all these reasons – gender, land, plus economic reasons – staple foods alone are not enough.”
Ms. Bhatty says the right-to-food lobby is not trying to turn back the clock: “It's not about a Gandhian utopia at all,” she says. “There are many good reasons to go local, starting with the fact that you need local buy-in if a scheme is going to be sustainable. Using local foods revives local practices, it boosts the local economy and it has environmental advantages.”
Underlying these political tussles are systemic failures of the Indian government – it has failed to prioritize public health, spending just two per cent of the national budget on health care, compared to 13 per cent on defence. There is ample research showing that cheap, relatively simple interventions can have a huge impact, yet none of these are as politically popular as food aid and none are happening at a large enough scale to bring real change.
And while even slum dwellers have doubled or tripled their incomes in India's economic boom, that is rarely enough to get them out of the slums into a house with sanitation and clean water, so their children continue to fall prey to monthly bouts of diarrhea and other illnesses.
THE MORE THINGS CHANGE ...
There are some stirrings of hope. A few weeks ago, for example, the government introduced its first new guidelines on feeding children since 1975. Last October, the budget per day per child for food supplements was doubled from half a penny to one cent.
The prime minister has appointed a commission on nutrition and promised funds, which Ms. Philpott finds heartening. “The fact that economic growth is so good and they are translating that into programs is a good sign.” The nutrition program's head, Mr. Arora, predicts cheerfully that this could all start to show results in five to 10 years.
Yet in Dehde, it all feels so far away as to be nonsensical. There is electricity for only an hour each night; girls in stained cotton saris collect water at the hand pump; women pat cakes of cow dung into circles to dry on the mud-house walls and burn for fuel. And nothing so far – no economic boom, no space program, no superpower status – has changed the basic truths for the Adivasi family.
“We don't have for ourselves so we don't feed the child – we are poor so we don't have these things to feed him,” Mr. Adivasi says, with equal parts resignation and defiance.
And after he has left the smoky dim of the family's one-room house, when Ms. Bai leans close and tries to urge Ms. Adivasi to do something for tiny, frail Devsingh, the young mother rocks squats back on her heels. “What can I do?” she asks softly. “What is there for me to do?”
Globe and Mail South Asian correspondent Stephanie Nolen was nominated for a National Newspaper Award in International Reporting this week for the sixth straight year.