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The face of famine

By Sandhya Srinivasan

Forty-three per cent of all children under 5 in India are underweight, and more than half of all under-5 deaths are linked to malnutrition. One in three adults too is underweight, and 60% of deaths due to infectious diseases are caused by the coexistence of undernutrition. These figures represent a composite index of chronic and acute deprivation and hunger. As Dr Binayak Sen says, the poor are walking with famine by their side

One of the most painful images in the collection of articles in this issue is of a boy hunched over a mortar and pestle while another little boy stands patiently by him. Dr Ramani Atkuri found Sumit preparing a paste of garlic so that his toddler brother could stave off hunger until their parents returned from the fields. It is a heart-rending story, about how the poor grow up early, how children care for other children, and how the destitute just cope. The tragedy is that Sumit’s story is not new. Dr Atkuri and others working among the poor in India are witness to such scenes every day.

The bigger picture is in the statistics. These faceless figures are no less distressing.

Forty-eight per cent of all children under 5 in India are stunted for their age -- the impact of longstanding hunger which, in turn, is a result of sheer poverty, marginalisation and a government that clearly does not care. Twenty per cent of children are wasted -- they are stick-thin because a drought or other crisis has forced the family to further cut back on food. And an outrageous 43% of all children under 5 are underweight -- a composite index of chronic or acute deprivation.

The Integrated Child Development Services (ICDS) programme is supposed to address this extreme deprivation by providing supplementary food, rations and growth monitoring through community-level anganwadis for children under the age of six years. However, though a whopping 70% of children in India between six months and five years are anaemic, 74% of children under 6 do not receive any supplementary food from the anganwadi in their region. Convert those numbers into more than 100 million children who don’t get enough to eat.

Hunger pursues the survivors of childhood into adulthood. More than one in three adults (36% of women and 34% of men) is underweight. Fifty six per cent of all women (and 24% of men) are anaemic. In turn, adult malnutrition casts a lifelong shadow over the health of the next generation: 59% of pregnant women are anaemic, and the NFHS indicates this figure is rising. The government has a programme to provide food supplements for pregnant and lactating women -- for their own health and that of their child (women past reproductive age are of no interest). But just 21% of pregnant women and 17% of lactating women received any food supplementation.

Needless to say, those numbers are averages. The picture is particularly bleak in Madhya Pradesh, Jharkhand, Bihar, Chhattisgarh and Orissa. It is influenced by multiple exclusions -- from food and health services to social marginalisation, affecting the scheduled tribes, scheduled caste communities and Muslims the worst. As eminent public health specialist Dr Binayak Sen says, the poor are virtually walking with famine by their side.

More than half of all deaths in India of children under 5 are linked to malnutrition -- it reduces their immunity to illness as well as the ability to fight it if they do fall ill. The Indian National Science Association notes that “60% of deaths due to infectious diseases are caused by coexistence of undernutrition”. Indeed, India ranks 41st among 41 developing countries in the prevalence of underweight in children -- it is twice as high as in 26 countries in sub-Saharan Africa.

There are scores of newspaper reports on children whose illness was hunger but whose cause of death is recorded as measles or diarrhoea. Alongside these reports are horrifying photographs of skeletal babies with distended abdomens. Like Raichur district in Karnataka which officially recorded an average of three malnutrition deaths daily in the last two years. Starvation death also strikes in Baran, Rajasthan, where the Sahariya tribals are rendered landless and destitute. It is a matter of disgrace that a Maharashtra minister can actually announce without shame that 1.17 lakh children died of malnutrition over four years -- or 80 children every day across the state. 

The urban poor are not much better off. The particularly marginalised, such as children of ragpickers and construction workers, are more at risk, without even token access to health and nutrition schemes. Twenty-six per cent of all children in Mumbai are underweight.

And surveys show that calorie intake has declined and the poor are eating even less today than they were 40 years ago. Government committees actually conclude that this drop is voluntary, and merits a reduction in the prescribed minimum calorie requirements, allowing it to further reduce the amount of grain available through the public distribution system (PDS), forcing the poor to pay market rates for food -- or do without. This is a scandal when families are cooking wild roots and leaves to stave off hunger.

In this issue of Agenda, researchers, physicians, journalists and health activists take a look behind such figures.

The first set of articles sets the stage for this discussion. Paediatrician Yogesh Jain describes how the massive burden of chronic as well as infectious diseases in poor communities, seen every day at a community health programme in Chhattisgarh, is clearly linked to food deprivation. Ramani Atkuri’s guide to terms explains how malnutrition is measured. In the first extract from her essay ‘The Career of Hunger: Critical Reflections on the History of Nutrition Science and Policy’, senior nutritionist Veena Shatrugna explains how politics conspired with science to develop a cereal-based diet bereft of animal protein, a diet which has played its part in promoting malnutrition and disease. Researcher Rahul Goswami goes through the latest data from the National Sample Survey 66th Round to summarise what people are eating. Activist Sachin Kumar Jain provides statistics to show that the poor spend more of their income on food, but get less to eat.

Reports from the field tell the stories behind the numbers -- how people survive. Mari Marcel Thekaekara in Gudalur, Tamil Nadu, spoke to community health activists across the country for a picture of malnutrition in adivasi communities, finding a direct link between land alienation and starvation. Aditya Malaviya visited Baran, Rajasthan, to interview families of Sahariyas, where starvation deaths are reported with depressing regularity. Rajashri Dasgupta talked to migrant workers, street children and the homeless in Kolkata who depend on roadside stalls for at least one meal every day. Shahina K K travelled toKarnataka’sRaichur district where anganwadis are stocked with packaged foods from a processed food company: “It is hard to tell which is the worse scandal: the lack of nutrition here or the money being made off it.”

The third set of articles focuses on the government response. In the second extract from her essay, Dr Shatrugna discusses the decision to focus on cheap calories and its influence on major policy decisions such as the low poverty line, a minimum wage to meet these low dietary requirements, a public distribution system limited to cereals, and high-input monoculture to produce these cereals. Rahul Goswami gives a macro analysis of the government’s approach to malnutrition -- providing space for industrial monoculture and the ready-to-eat food industry. Government programmes with great potential, such as the ICDS and the PDS, have been sabotaged. The commodification of malnutrition is discussed in more detail by health activist Radha Holla, as the government forges partnerships with companies making biscuits and baby food -- and running mines. The same private interests also fund non-governmental organisations that promote biscuits as nutrition. Paediatrician Vandana Prasad presents the position paper of the Working Group for Children Under 6, attacking the government’s use of a commercial product for treatment of severe acute malnutrition when locally made foods are effective, appropriate and cheaper.

Thefinal set of essays looks at what can be done. Paediatrician Sridhar Srikantiah looks at various approaches to addressing malnutrition, to see what works and what does not. In tribal Orissa, community physician John Oommen and his colleagues found that most severely malnourished children there also had malaria -- and when the malaria was treated, the children finally started putting on weight. Ramani Atkuri describes a successful creche programme in Chhattisgarh, a contrast to the government’s ICDS. Can the JSS (Jan Swasthya Sahyog) model be replicated by the government? Sharmila Joshi interviews neonatologist Armida Fernandez on theachievements of the breastfeeding-promotion network, and barriers yet to be overcome. 

Community involvement -- through feeding programmes, self-help groups, grain banks, and so on -- has a critical role to play in tackling malnutrition. But it is of limited value unless the government acknowledges its obligation to ensuring people’s right to food. The flaws in the National Food Security Bill are touched upon by many writers in this issue of Agenda (see for detailed discussions on the bill). Without an assurance of sufficient food through the PDS, people are left to the mercy of the market -- and the consequences are evident. So it is a matter of concern that even as the government talks about expanding food security, we read of proposals for conditional cash transfers that would effectively wind down the PDS. In the last piece in this issue, Biraj Patnaik discusses the work of the Right to Food Campaign. Finally, people must act through civil society organisations to get the government to meet its commitment to the country’s poor and hungry.  

(Sandhya Srinivasan is a freelance journalist specialising in public health and development issues. She has a Master’s in public health and is Consulting Editor of the Indian Journal of Medical Ethics and Consulting Editor, Public Health, for She was a Panos Reproductive Health Media Fellow in 1998 and an Ashoka Fellow)

1 Arnold, F, et al. Nutrition in India. National Family Health Survey 3, India, 2005-06. Mumbai: International Institute for Population Studies; 2009
2 Hunger and Health: An Interdisciplinary Dialogue. Joint statement from a workshop. Bilaspur, February 10-11, 2006. mfc bulletin. 2006 February-March.
3 Sen, Binayak. ‘Ethics, equity and genocide’.  Indian J Med Ethics. 2011 January; 8 (1): 12-15.
4. The Right to Food Campaign.

Infochange News & Features, July 2012