At the foothills of a dumping ground that is a half-hour drive from the Bandra-Kurla Complex, Mumbai's upcoming, ultra-modern business district, in a house made of tarpaulin and wooden planks, Gulnaz Sheikh lies on her mother's lap, too weak to sit or stand.
Gulnaz, who turned one in September, weighs five kilograms and measures 55 centimetres, both of which indicate that she is malnourished or, to be more specific, undernourished. This means that she does not have enough nutrients to fight infection.
The World Health Organization classifies a girl who at one weighs less than 6.3 kilograms and measures less than 66.3 centimetres as "severely malnourished", a definition that the Indian government also uses.
"Gulnaz needs immediate attention," said Shobha Udipi, head of the Food Science and Nutrition department at SNDT University, who headed a research project two years ago on the nutritional status of 5,000 children in Mumbai slums. "Her physical and cognitive growth are at risk in the long term, if she survives."
Gulnaz, who lives in the Shivaji Nagar slum in Mumbai's Govandi locality, is far from an aberration. In the shadows of glitzy residential skyscrapers and business districts, Mumbai's shanties are in the grip of a silent malnutrition crisis.
Between 40% and 60% of the city's nearly 7.3 lakh slum children up to four years of age are malnourished and between 7.5% and 30% are severely malnourished. The Indian government puts the figures at the lower end while academics' and social workers' estimates are at the higher end.
Even if you accept the government's lower figures, they point to appalling inequalities in the financial capital of one of the world's fastest-growing economies. Even government data show that about 3.5% of Mumbai's slum children die before they turn six.
"Malnourished children who do survive find it more difficult to cope with academics and physical activities and have a high tendency to drop out of school," said Neeraj Hatekar, a professor of economics at the University of Mumbai who conducted a study of malnutrition in the city's slums seven years ago. "In an economy driven by skilled labour, these children can never find a way out of the cycle of poverty."
The scale of malnutrition in Mumbai suggests a failure in the delivery of government services, in particular, the 35-year-old Integrated Child Development Scheme, the central government's primary means of addressing malnutrition countrywide among children up to six years and pregnant and lactating women.
On the ground, the scheme works through state governments, which operate special centres called aanganwadis in vulnerable pockets. In urban areas, these are mostly in slums.
The central government provides roughly two-thirds of the funds and the state governments the rest. In all, Maharashtra has Rs. 1,700 crore to spend on aanganwadis in the current financial year through March 2011.
The centres are supposed to stay open from 9 am to 2 pm and offer a range of free services to children below six years. These consist of providing lunch and day-care facilities as well as conducting monthly health check-ups, including closely monitoring the growth of children up to three years of age and immunising them.
If workers find a child is malnourished, they are supposed to ensure that he or she is given food with extra calories and the right nutrients, and to refer them to the nearest primary health dispensaries, run by the civic body.
Many mothers and children are, however, falling through the scheme's many cracks. First, Greater Mumbai has just 5,132 aanganwadis for a slum population of nearly 83 lakh people, a ratio of 1 centre for 1,600 people, instead of the 400 to 800 slum inhabitants that the scheme recommends. This means the staff is handling double the load.
State failure perpetuates a vicious cycle
The state also does not have enough supervisors to monitor the centres. One child development project officer is meant to supervise 150 centres, but just 12 of them are now monitoring all the centres in Mumbai, which means that quality control inevitably suffers. "We noticed that aanganwadi workers do not regularly check children's weights," said Dnyaneshwar Tarwade, assistant health director for Apnalaya, a non-profit group that works with slum residents in Govandi.
The aanganwadi workers say they are overworked, underpaid and do not have the resources to do their job (see "A moving roof and other failures").
Rajesh Kumar, who heads the central government scheme in Maharashtra, says it would work better if the state ran its own health dispensaries dedicated to underweight children.
This is because many children who are underweight but can yet be helped often fall ill. But the civic dispensaries serve the whole slum population and cannot give the children the attention they need, Kumar explained.
"Once an infection sets in, it puts nutritional pressure on the child to overcome it, which makes the child weaker and more susceptible to illness," said RD Poddar, a Mumbai-based paediatrician who works with slum children. "It's a vicious cycle."
The state government now sets up aanganwadis wherever a group - whether of slum residents or members of a local non-profit - approaches them to do so, says Dattatray Mundhe, deputy commissioner for the scheme in the state.
But perhaps the more sensible thing for the government to do is to identify vulnerable pockets and deploy its limited resources in those first, say experts.
Gulnaz is living proof that the scheme has huge lacunae. In her case, it failed to tackle the root of the problem: which was her mother's health. Even though the local aanganwadi was supposed to monitor pregnant women, Gulnaz's mother, Aasma, 27, who gave birth to her first child when she was just 19 years old, has never taken a nutritional supplement during any of her five pregnancies. "When an undernourished mother gives birth, the child is born with a disadvantage," said Udipi from SNDT University. "Early marriage is also a problem because the mother's body is not mature enough to bear children."
Nearly 97% of women in Mumbai slums received no services from the scheme during pregnancy and 99.2% received no services while breast-feeding, according to a 2006 National Family Health Survey. This was conducted among 1,104 slum households and 1,107 women by the International Institute of Population Sciences in Mumbai.
The supervisor of the aanganwadi in Gulnaz's slum said that his colleagues did try to help Aasma but were unable to convince her to change her diet.
"Cultural factors, including superstition, hinder our work," said a worker, who did not wish to be named.
But her supervisor admitted that aanganwadi workers were not trained to negotiate cultural barriers, yet this was crucial for the scheme to work.
Social workers admit that the scheme does help to an extent, especially in rural areas, and that many children and women would be worse off without it. The solution, therefore, is not to do away without it, they emphasise, but to strengthen it.
At the same time, academics like Hatekar argue that food security programmes cannot work in isolation.
What's needed: Basic healthcare and water
Malnutrition is a manifestation of a deeper problem of poverty, said Hatekar: "It can't be addressed by focusing on food security. Also, its context in Mumbai differs from that in tribal areas, so you cannot use the same scheme in both places."
Population densities and exposure to infections in urban slums are much higher, pointed out Anjali Kantikar, a professor at the Nirmala Niketan College of Social Work in Mumbai, who has worked with malnutrition in tribal areas.
If India is to eradicate extreme hunger, the first of the UN's seven Millennium Development Goals to which it is committed, it must not only strengthen its food security scheme but also improve access to clean water and healthcare, and ensure job security for unorganised labour, said Hatekar.
Take water. It costs Rs. 15 and Rs. 30 for five litres in Gulnaz's slum. Her family's monthly income is Rs. 3,000 and, with seven mouths to feed, her mother Aasma can afford to buy only ten litres a day to use for drinking, cooking, cleaning and bathing. "Water is a major source of infection," said Poddar.
Healthcare is also a problem. Gulnaz, the youngest of Aasma's five children, is sick for three weeks every month, suffering from diarrhoea and fever, her mother said. The nearest public dispensary is two kilometres away. Mumbai has just 183 public health posts and 162 public dispensaries for 82.8 lakh slum dwellers, all run by the municipal corporation. The health posts mainly give out contraceptives while the dispensaries treat patients. But each dispensary has just one doctor seeing 50 to 200 patients a day, said Dr Girish Ambe, a senior civic health officer. If both parents work, it is hard for them to find time to stand in dispensary lines, said Udipi.
"Simple solutions such as mobile health clinics can go a long way in filling the gap," said Hatekar. The Centre for the Study of Social Change, a non-profit group founded by Poddar, runs such clinics in some city slums. "If we have to be a strong nation, we need a strong workforce, not a generation that grows up malnourished," he said.
(Tracking Hunger is an HT/Mint initiative to investigate and report the struggle to rid India of hunger. You can read previous stories at www.hindustantimes.com/trackinghunger)
Mumbai's hunger map | Mumbai's population | A moving roof and other failures