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Health through the hunger lens

By Yogesh Jain with Jan Swasthya Sahyog

In tribal-dominated Chhattisgarh, where this writer works, men and women are at least 10 kg lighter than the reference Indian, and even the popular PDS rice scheme lasts a family only 11 days. The high burden of all diseases, from TB and malaria to cancer and heart disease, has clear links with the 'lifestyle' of poverty and hunger in this region

On February 8, 2012, 36-year-old Dhansai Portey walked into our out-patient department. He was the image of a person literally consumed by tuberculosis. Though normal in height, he weighed just 35 kg. An x-ray of his chest revealed lungs that had turned almost white from the disease (normal is black). For the last six months or so, he had been experiencing several symptoms and had become too weak to pull a rickshaw to earn his living in Bilaspur, Chhattisgarh, in central India.

For me this was a familiar picture of deprivation and injustice, of which disease is only the embodiment. I have become immune to such medical situations which can only be described as 'violence'. The low body weight (at 36, Dhansai weighed as much as a 12-year-old child) led me to check for other causes of immune deficiency, such as HIV. Thankfully, these were negative. Dhansai told me that for the last six years he had been living with his wife and three children. Through the much-applauded public distribution system (PDS) in Chhattisgarh, he received 35 kg of rice a month, at Rs 2 per kg. He ate almost nothing else. In fact, little remained of the Rs 70-80 that he managed to earn from his rickshaw every day: Rs 400 was spent on rent for his one-room tenement, and another Rs 100 went on electricity every month.

I thought about the drugs he should take; I worried whether he had acquired a resistance due to irrational anti-TB drug combinations prescribed by other doctors; I thought about the points that needed to be stressed during counselling; I wondered whether his weight loss was due to lack of food or because his symptoms had been ignored by the health system.

Records of his previous visit to Jan Swasthya Sahyog (JSS) seven months earlier showed his weight at 43 kg. He had come to look after his sister who was being treated for advanced tuberculosis requiring hospitalisation. Dhansai believed he had developed tuberculosis because he had been sleeping on the cold hospital floor. The physician who saw him then had prescribed analgesics for his bodyache and given him some iron tablets for his mild anaemia.

poverty and hunger

This long story taught me many things. One striking lesson was that we should have recognised that Dhansaiwas already at risk of developing tuberculosis when he came in with his sister last May. Though 8 kg heavier, he was already at much greater risk than someone like me, at 65 kg, who sees, along with others at JSS, over 500 new tuberculosis patients every year. Even in an organisation that is committed to understanding hunger as it relates to health, we did not appreciate Dhansai's greater risk of becoming a victim of what can only be called a 'disease of poverty or hunger'. Should something have been done when Dhansai first came to us at 43 kg?

Hunger

When I say that one-third of all men and about half of all women in India have weights or body masses less than Dhansai's 43 kg, it is not a mere nutrition statistic. Statistics confuse most of us, yet they are enormously significant. What the numbers tell me is that a large proportion of our people are at great risk of contracting illnesses like tuberculosis and worse. They are also less likely to survive these illnesses even if they do manage to receive the best treatment available. Those who survive may be left unable to work. Yet these facts do not impinge upon our consciousness, or even our conscience. Spurred on by Michelle Obama, American society, which recognises that the health costs of obesity due to overeating runs into billions of dollars, unleashes programmes to address the problem. We, on the other hand, occasionally distracted by the 'HUNGaMA' of statistics (1), continue to be blissfully smug and ignorant about the huge health costs of undernutrition, or its less sanitised synonym, hunger.

If the first question that occurred to me was: Should something have been done for Dhansai when he first came to JSS, the questions that followed were: What are 'good weights' for men and women? What about height? How does height and weight translate into an ability to earn, or into being healthy or unhealthy? How much food does a person require to remain healthy or to maintain a normal weight? What amount and type of food should the right to food entitlements and security and the right to good health translate to? And finally, when whole communities remain hungry what are the consequences on their health, at different points in life? Where do the present food entitlement programmes lead us? And is there hope for them?

I will explore some of these questions from the vantage point of the junction of health and hunger, situated as I am in a community health programme in an area where deprivation is entrenched; where, in fact, deprivation is actually promoted by the exploitation of rural areas, ineffective development programmes, and a public distribution system that has increasingly restricted its coverage. All of these lie within the rubric of structural violence.

If one gets enough to eat, the National Institute of Nutrition (NIN) recommends that, as a reference, a rural Indian adult man should weigh 60 kg and be 173 cm tall, and a woman should weigh 55 kg and be 161 cm tall (2). These obviously are the ideal to which one must aspire. The mean heights of both men and women in India are lower than these references or standards by a little more than 10 cm. The National Family Health Survey does not publish data on weight alone, but it does give information on body mass index (BMI), a derived indicator representing weight for height, which is another measure of nutritional status. According to NFHS-3 data, going by the standards of BMI, as many as one-third of India's adults are undernourished, with a BMI of less than 18.5. There is also a clear pecking order in the social group, with scheduled tribes faring the worst, followed by scheduled castes, other backward castes, and the general category, in that order. There are also variations between states (3). At JSS, among the people in tribal-dominated forest fringe villages, the median weights of men and women are 49 and 41.5 kg respectively, or at least 10 kg lighter than the reference Indian. And this has not changed in the last decade that we have worked here and collected such information.

Why are we so fixated on weights and heights? The reason is that these measures are robust indicators of food security. If you discount those who have certain psychiatric problems, no one would have a lower weight or height if he/she had access to adequate food. The proof of the pudding is in the eating. We can judge all processes like the efficacy of the PDS, the importance given to growing food crops, and the purchasing power of people by looking at body parameters like their weight and height. Besides, a person's height can also tell us whether adequate food was available during his/her childhood.

Why should we call undernutrition hunger? Let me give you a reason. Nutritionists say that to lose (as well as to gain) each kilo, the cost would be 7,000 calorie units. NIN and other bodies recommend 2,325 and 1,900 calories for the sedentary Indian man and woman respectively, and additional calories for physical work (4). As mentioned above, Indian men and women weigh at least 10 kg less than what they would have weighed had they been eating well. Thus, the hunger cost of their nutrition is 70,000 calories. Even if we assume that an average Indian goes hungry by 500 calories every day, it would take at least 140 consecutive days to reach that state.

We can still choose to describe underweight and stunted people as 'malnourished' if we like. But I suggest the correct term would be 'hunger'.

How did food security get reduced to food 'entitlements'? That too, targeted at the officially poor? And that in turn into cereals alone? And that too into a magical figure of 35 kg, or, worse, 25? This is beyond my comprehension. One administrator in my own state of Chhattisgarh said it was his personal assumption -- not based on any research or guideline -- that an adult required 10 kg of cereals every month and a child 5 kg; thus, a family of five that had three children required 35 kg. Simple! The Food and Agriculture Organisation recommends that every person living on a predominantly, though not exclusively, cereal-based diet requires about 18 kg per month (5). Our studies in Bilaspur, with an average family size of 5.5, aimed to look at how long PDS rice lasts. We learned that PDS grain (35 kg per family) lasts just 11 days. That leaves families to fend for themselves for the rest of the month, from the market or from their own produce. And the Food Security Bill is aiming for 25 kg per family!

Why only cereals? The Chhattisgarh government has piloted giving 2 kg of channa (gram) monthly to the officially poor in Bastar and Sarguja divisions; this may be extended to the rest of the state. It experimented with providing 1 kg of oil at a little less than the market rate, but that did not succeed. In Chhattisgarh, the JSS has recommended that the state implement a better PDS that would meet more than half people's calorie and protein intake (6). We hope that the state will heed our plea.

Has the presence of a PDS ever shown an improvement in people's nutritional status, or in their food intake? I have not found any studies to show this, although some are still underway. It seems to me that at the very least, given that there are so many needs, the money saved due to the availability of subsidised foodgrain from the PDS allows people to buy other things, possibly other foods. With PDS food lasting just a few days, families are victims of spiralling food prices in the market.

Yet it is true that the public distribution system is quite popular, allowing the present government to come back for a second term. Efficient overseeing of this programme has plugged leakages, delays and non-delivery. It has weathered criticism from the middle class that people are less interested in agriculture due to easy availability of foodgrain for a majority of working people. Yet, it is inadequate. The people of Chhattisgarh have some of the poorest nutrition indicators in the country.

The consequences of food deprivation

How do we view the food situation from a health window? What we see are massive levels of morbidity which can be shown to be a consequence of deprivation, of which food deprivation is the most important one. In our clinics, we check the weights of everyone who attends any level of our health programme, and are astounded to find that the median weights of men and women are 42 kg in women and 49 kg in men. It may be argued that these are patients and therefore they have low weights. However, even among the healthy in the community, with 79% of them being adivasis, the median BMI is 19.1 among men and 18.4 in women, and the median heights are 160 cm and 151 cm respectively. These are in some ways not much worse than what is seen at the state or the country level. Given the stark association in our community between undernutrition on the one hand and high rates of disease and death on the other, we can easily imagine the situation across India for the deprived people of an entire country.

The first point that strikes us in our work is the massive numbers of people with sickness of all types. The prevalence rates of chronic illnesses like rheumatic heart disease, rheumatoid arthritis, cancers, asthma, low body weight, diabetes, hypertension and severe anaemia surprised us for some time, but now seem to make sense. The incidence rates of new illnesses like upper respiratory illnesses, pneumonias and soft tissue infections and tuberculosis are higher than we have seen in most literature on the health status of rural Indians, which itself is scarce. While the purists may question whether these huge numbers are directly attributable to hunger or food deprivation, or whether they should rather be associated with 'poverty', the weights and heights of people with these illnesses are compelling enough for us to attribute these diseases to food deprivation. At another level, we feel it is unnecessary to disentangle food deprivation from other forms of deprivation.

The second point is about the types of illnesses. If illnesses are biological 'embodiments' of deprivation, then we can really see the 'soul' of food deprivation through the illnesses. For example, we see a higher than expected incidence of maternal exhaustion during delivery, leading to higher caesarean rates for women with lower body weights. We also see a higher percentage of deaths in people with tuberculosis, among those with lower body weights. Likewise, there are a massive number of hernias among underweight men.

We have wondered why we have malaria incidence and deaths peaking in November and December, months which are relatively cool and have lower mosquito biting rates (Figure 1).

Figure 1: Is malaria related to food availability or to nutrition?

Figure 1-2: Seasonality of malaria 2002-2011, JSS Bilaspur

In most discussions on infectious diseases, the focus is on the agent -- the bacteria, virus or parasite -- the vector, and sometimes the environment. There is very little interest in the host, the person who suffers the illness. For example, in TB, one is obsessed with the bacteria and its spread through sputum, but not in people's weights which are so much more important. In malaria, the obsession is with resistance in the malarial parasite, or the mosquitoes, or water stagnation. There is very little about the determinants of the human being's vulnerability. One of the most important determinants is nutritional status.

In most of India, the major crop is sown pre-monsoon, in May-June, and harvested around November. Thus, food stocks for most people become available in December and then decrease over the year, even if there is a smaller, second crop. Food stocks are lowest just before the annual harvest in November. Indeed, when we check people's weights through the year, we find that weights are the lowest around harvest time. We suggest that the 'unseasonal' malaria outbreaks in central India are precipitated by the dip in nutrition in November and therefore an increased vulnerability in the host.

No one who works with malaria can deny the plausibility of this hypothesis. In fact, the association between hunger and malaria deaths has been elegantly argued in a study done almost a century ago in rural Punjab (7).

While tuberculosis, malaria, soft tissue infections, pneumonia with complications, and diarrhoeal deaths may be accepted as being due to the body's low immunity from hunger, which may have allowed these bugs to damage weak bodies, what surprised us is the pattern of what are called non-communicable diseases, or NCDs (Figure 2). The dominant discourse clamours for the recognition that NCDs are an emergency (8), and India is a diabetes capital.

Figure 2: Community burden of illnesses in rural Bilaspur, JSS 2011

The World Health Organisation has a uniform, single explanation for this problem -- the nutritional transition, or an improvement in people's nutrition, which gives rise to a new set of NCDs. But this discourse attributes NCDs to a sedentary lifestyle, an excessive intake of high-calorie refined foods with little of the fibre contained in fruit and vegetables, and tobacco use. Data from urban and peri-urban clinics and surveys links NCDs to increasing rates of obesity and higher weights. While this may be true in urban areas, the profile of NCDs in rural areas has not been given due importance. In rural Bilaspur, we see a high prevalence of hypertension in the community; 16% of rural women more than 30 years old had hypertension and their weights or heights were not higher than in those without hypertension. In other words, their condition was not due to their nutrition. In 2011, we saw 400 new patients with cancers, 89 with rheumatic heart disease and 258 patients with diabetes (Figure 3). Similarly, 80% of people with diabetes seen here have low or normal weights, something that is the inverse of what is seen in urban areas. As a group of diseases, cancers are the second most prevalent morbidity at the JSS clinics, next only to tuberculosis. In fact, it would be appropriate to say that patients with diabetes or cancer or tuberculosis, in Ganiyari in Bilaspur, have more similarities to each other in terms of weight, dietary predicament, social and economic status than to people with the same biological ailment in a city like Delhi or Mumbai. We feel that NCDs in rural India are clearly linked to the same deprivation of food and other human needs as are tuberculosis and malaria; they are not linked to affluence. Illnesses are, in fact, reflections of local deprivation rather than mere biological events with universally common appearances.

Figure 3: Burden of major illnesses seen in the JSS community health programme, rural Bilaspur, January-December 2011

Illness New patients seen
Tuberculosis 587
Leprosy 132
Hypertension 478
Rheumatic heart disease 89
Cancers 400
Condition requiring surgery 1,473
Sickle cell disease 99
Diabetes 258

There are some serious implications of neglecting the association between hunger and NCDs in mainstream discourse. If there is going to be a homogenous preventive clarion call for reducing NCDs by eating less, working or exercising more, and by stopping tobacco for both urban as well as rural people, for those who are overweight as well as those who have low weights, then there is a problem. If the 'lifestyle' of poverty and hunger that seems to be associated with these illnesses in rural central India is ignored and all NCDs globally are attributed to a sedentary lifestyle and excess consumption, then there is also a moral problem. In fact, by correctly highlighting the association between NCDs and deprivation, we can more strongly advocate another good and strong reason to ensure adequate and balanced food for all. The bluff of the WHO should be called.

Besides infectious diseases and NCDs, there are the core diseases of undernutrition, which deserve a third category. Rates of anaemia, including severe anaemia -- due to iron deficiency as well as malaria -- are frightfully high in both women and children, and are not much less in men (9). While both mental and physical symptoms are attributed to even lower grades of anaemia for the rural person, it is the beginning of a vicious cycle of poor earning power, resulting in a reduced ability to purchase food, and so on. For a labourer, working with anaemia is like doing the job of a bull with the energy levels of a cow. Besides, it can't be stressed enough that anaemia poses the greatest risk of death and morbidity for women in labour because of a clearly increased chance of post-partum haemorrhage, which is the most important reason for maternal deaths in our country.

What about minerals other than iron? Most of them come from wholesome food that is associated with affluence. This includes foods that come from animal sources. Total body potassium falls in all patients with severe undernutrition, and this can lead to profound weakness. Similarly, calcium is a mineral that is more available in animal-based foods and its deficiency occurs due to deficiency of these foods plus the increased burden that women incur when they bear and suckle their babies, as calcium is extracted by the foetus as it grows, and then in breast milk. Its deficiency can cause severe painful spasms and weakness. Zinc too is a mineral of affluence and is often deficient in poor people's diets. While much is written in praise of this mineral, the best possibility of alleviating its deficiency comes from the consumption of more wholesome foods as well as increasing soil concentrations of the mineral.

And vitamins? We have a really confusing situation here. Certain minerals and vitamins are being promoted for the prevention of disease or to augment the effects of drug treatment. Micronutrient initiatives are posited almost as an alternative to the basic 'macronutrients' of calories and protein. We need to very carefully assess the health consequences of vitamin deficiency. In rural Bilaspur, we see high rates of night blindness among the poorest women during lactation and pregnancy. Vitamin A has reparative properties: it helps in the healing process, building tissue destroyed through infections. Deficiency of this vitamin can have important consequences in a situation where infections, even if they are minor, are so common. But it may be prudent to say that vitamin deficiency almost mirrors the deficiency of macronutrients, and thus ensuring food in a balanced way will surely be able to look after these deficiencies too. There do not seem to be compelling health reasons to have special vitamin deficiency treatment programmes.

The biggest wealth of poor people is their ability to labour. Thus, the biggest health consequence of poor nutrition that we see is in the ability to labour. This ability is clearly affected by lower weights and heights. This translates to poor earnings which, by reducing the purchasing power of people, results in a continuation of the vicious cycle. Given the fact that wages are given according to work output, according to prescribed rates, it would be interesting to see how the weights of people correlate with their work output and earnings at MGNREGS sites. It seems that people with hunger and poor weights are at a disadvantage compared to their peers who eat better and weigh more.

The unfairness of this is complete when one realises that all calculations of caloric requirement that may go into any food distribution systems are defined on the basis of a sedentary lifestyle. Who cares that people with heavy work schedules and who live off the land need almost double the amount of food compared to those who live off the pen or their minds!

Note: Jan Swasthya Sahyog runs a community health programme in rural Bilaspur, central India, that includes a clinic and hospital where people from over 1,500 villages come for treatment for major health problems

(Dr Yogesh Jain has an MD in paediatrics from the All India Institute of Medical Sciences in Delhi. He has been involved in issues of access, cost and quality of healthcare, specifically in hunger and health, communicable diseases control programmes, and technical aspects of women's health. He is a member of the Planning Commission's High Level Expert Group on Universal Coverage for India. He is a founding member of the Jan Swasthya Sahyog in Bilaspur, Chhattisgarh state. The ideas expressed in this article have developed through the work of the JSS collective)

Endnotes

1 The HUNGaMA Survey Report 2011. Available at www.naandi.org/CP/HungamaBKDec11LR.pdf
2 'Nutrient Requirements and Recommended Dietary Allowances for Indians: A Report of the Expert Group of the Indian Council of Medical Research'. New Delhi: ICMR; 2009. pp 24-9
3 National Family Health Survey-3, 2005-2006. Chapter 10. 'Maternal and Child Nutrition. Nutrition and Anaemia'. p 304
4 ICMR, 2009. p 66
5 Indian Experience on Household Food and Nutrition Security: Nutritional Requirements in India. www.fao.org/docrep/x0172e/x0172e02.htm
6 Jan Swasthya Sahyog. 'An Enhanced PDS for Better Nutrition and Health of the People: Suggestions for Implementation in Chhattisgarh'. Recommendations submitted to the chief minister and chief secretary. 2011. March 18
7 Christopher S R. Malaria in the Punjab, Calcutta: Superintendent Government Printing. 1911
8 Narain J P, Garg R, Fric A. 'Non-communicable Diseases in the South East Asia Region: Burden, Strategies and Opportunities. National Journal of Medicine. India. 2011; 24: 280-7
9 NFHS-3. p 288

Infochange News & Features, July 2012