At a time when India plans a multi-pronged attack on malnutrition in 200 high-burden districts, it will pay to examine the cracks in state institutions that have led to past failures and can still derail well-intentioned plans.
Melghat, a tribal corner in the northeastern fringes of India's richest state-Maharashtra-is an apt example of almost everything that has gone wrong in India's response to malnutrition and child deaths.
Every 14th child dies in Melghat before reaching the age of six, often owing to malnutrition-related causes. The statistic has remained largely unchanged over the past five years and puts Melghat almost at par with less-developed sub-Saharan nations such as Senegal and Tanzania.
Story in numbers
TRIBAL HEALTH INDICATORS
A tribal child is 25% more likely to be underweight and 40% more likely to die before five years of age compared with an average Indian child.
The proportion of low birth weight children at around 23% as well as the proportion of neo-natal deaths at roughly 40% is similar for tribals and others.
However, more tribal children die in the 1-4 age group compared with others, according to the World Bank.
Tribals account for 11.7% of all children under five, but account for 14% of under-five deaths and 23% of all child deaths in the 1-4 age group in India.
Melghat, with an under-five mortality rate of 74, has twice as many children dying before the age of five as Iraq. - Pramit Bhattacharya
The fate of tribal children in Melghat mirrors that of children in other parts of tribal India and reflects the yawning chasm between tribals and others. Nearly one in two tribal families are poor in rural India, according to the latest official estimates, a ratio that is 40% higher compared with the rural average.
Melghat also demonstrates the ineffectiveness of state-sponsored schemes such as the National Rural Health Mission (NRHM) and the Integrated Child Development Services (ICDS) in improving child health.
India's poor record in tackling malnutrition has come to the fore once again after the recently published results of a survey led by non-governmental organizations (NGOs) such as the Naandi Foundation found rates of stunting or chronic under-nourishment to be 59% across 100 districts, 11 percentage points higher than what the National Family Health Survey (NFHS) recorded across India in 2006.
Just like everything else in the nation, the spread of malnutrition is uneven. The inequality in malnutrition rates is higher in India than in most other nations, a February report by Save the Children said.
Tribals are the worst affected and are the only social group that saw a rise in the rates of stunting between 1992 and 2006, according to NFHS data. Yet, malnutrition rates in the country can improve only if tribal malnutrition rates drop. As a World Bank report pointed out in 2005, a quarter of Indian districts-many of them tribal-account for over half of India's malnourished children.
In Melghat, a shoddy health care system and ineffective ICDS workforce have contributed to the stasis in child mortality rates but the root of the problem lies in the apathy of the political and administrative class that has failed to address either poverty and livelihood issues or deliver basic public goods.
A severely malnourished child with her mother at Adnadi village. Her daily duties of tending to a newborn and working in the fields don't allow her to take her child to a public hospital. Photo by Pramit Bhattacharya
The villages of Melghat-with treacherous roads, closed schools and mostly without electricity or piped water-appear to be in a time warp, left behind by India's famed engine of economic growth. In several villages, child deaths are more frequent than the visits of public servants.
Other tribal areas of the state with the second-largest tribal population in the country tell a similar tale. Maharashtra is one of the better-performing states when it comes to tackling malnutrition, but its progress hides deep inequalities.
Story in numbers
INDIA IN THE WORLD
Half the 7.6 million under-five deaths in 2010 occurred in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China.
India (22%) and Nigeria (11%) together account for a third of all under-five deaths, according to the latest United Nations estimates.
With an under-five mortality rate of 63, India falls in the bottom quartile of countries in the world, according to the World Bank and ranks a lowly 165th.
Malnutrition statistics are worse: India is nearly at the bottom, with a third of the world’s malnourished children. India’s score in the global hunger index 2010 is described as alarming and the country is ranked a lowly 67th among 84 nations surveyed, below nations such as Sudan, Rwanda and Pakistan.
The global hunger index, developed by the International Food Policy Research Institute, is based on three key indicators: child malnutrition, rate of child mortality and percentage of people who are calorie-deficient. - Pramit Bhattacharya
Five tribal districts out of a total of 35-Amravati, Gadchiroli, Nandurbar, Nashik and Thane-account for a third of severely malnourished children in the state. The number of child deaths in some of these districts has grown in recent years. According to official estimates obtained through Right to Information applications by a Melghat-based NGO, Khoj, the number of child deaths went up 17% in Gadchiroli and 10% in Nandurbar in the past three years.
Melghat, composed of two blocks in Amravati district-Dharni and Chikaldhara-is special though, as it has the longest recorded history of child deaths and has seen decades of well-meaning judicial interventions starting 1993.
Media-savvy NGOs have managed to keep the spotlight on malnutrition and several politicians have made flying visits but life in Melghat has not changed much. A child in Melghat is thrice as likely to be severely malnourished compared with an average child in Maharashtra, according to ICDS data.
To be sure, the number of health centres has gone up in the past five years: a new rural hospital and a primary health centre (PHC) have been built, thanks to NRHM funding. The number of vacancies among PHC doctors has dipped to nearly zero.
Yet, such statistics hide more than they reveal. A third of PHC doctors are temporary, fresh out of college, and working for the government to fulfil their course requirements. Many doctors have been trained in traditional medicine but prescribe allopathic medicines with impunity. Although there are a few committed doctors, and the health department is better run than most other state agencies in Melghat, the overall quality of healthcare is poor.
Often, incompetent doctors get away even after making grave mistakes. When one-month-old Sachin Bethekar of Hatru village had diarrhoea in June, his parents took him to Hatru's PHC, where he was put on a saline drip till his stomach bloated. Sachin's distressed parents took him to a traditional healer or bhumka, who failed to help and he died the next day.
Saline injections to malnourished infants are a major cause of death in public hospitals although World Health Organization (WHO) guidelines forbid such treatment, said Ashish Satav, a physician and president of Melghat-based NGO Mahan. Nevertheless, the devastating impact of the saline drip finds no mention in the child death register at Hatru's PHC. It instead identifies the bhumka as the cause of death!
Health workers are as aware as other public servants that the chances of getting caught are slimmer than the chances of finding a healthy child in Melghat. Not surprisingly, such tales repeat themselves across Melghat. The details vary: in some villages, one came across stories of inadequate rations in crèches run under ICDS, in others of absent doctors, or of insensitive staff and petty corruption.
Sachin's uncle Sakharam Bethekar points out that this is not the first such experience the family has had in a public hospital: Sakharam's wife died while giving birth to a boy four years ago. Such incidents lead to a loss of trust in the public health system, said Bandu Sane, an activist with Khoj.
Across tribal India, the picture is equally bleak. A tribal child is 40% more likely to die before the age of five compared with an average Indian child not because he falls sick more often owing to malnourishment, but because he is half as likely to receive proper care, analysis of NFHS data by World Bank economists show.
Throughout history, tribals had a survival advantage over their peers, wrote demographer Arup Maharatna in his oft-cited book on the subject, Demographic Perspectives on India's Tribes. Till the early 1980s, tribal children had lower chances of dying compared with their closest social group, the scheduled castes, but mortality rates reversed in the past three decades as tribals lagged behind others in access to healthcare and basic amenities.
This decline in health of the country's most deprived social group has occurred precisely when the economy has grown at its most rapid pace ever, clocking an average of around 6% over the past three decades.
The blatant violation of norms and the years of neglect in Melghat arise from wide-ranging state failures and the inability of a weak tribal leadership to demand change.
In Katkum village, children walk on stilts. It is a popular pastime. Photo by Pramit Bhattacharya
"Our leadership has failed us and anyone who takes up the cudgels on behalf of our community is either intimidated or bribed very easily," said Kalu Bethekar, a plain-speaking health counsellor at Hatru's PHC.
Funds for tribal development often lie unutilized or are diverted. In many tribal areas of the state, there is no officer to plan projects, since many consider appointments in such areas as a punishment posting.
Maharashtra is among the eight laggard states, which did not allocate funds in the tribal sub-plan-a part of the annual plan-in proportion to the tribal population of the state, despite repeated pleas from central government agencies, according to a 2011 tribal affairs ministry report.
Maharashtra has a 9% tribal population but allocated only 8.2% of its annual plan allocation to it. The actual expenses are invariably lower than what is planned. Maharashtra has spent less than 2% of its annual budget on the tribal plan on average in the past decade, according to a 2011 report by Thane-based NGO Samarthan, based on official statistics.
In 11 tribal dominated blocks of the state, an Integrated Tribal Development Project (ITDP) officer looks into the implementation of all projects related to tribal welfare. Such posts often lie vacant, and even when appointments are made they are for a brief period, according to the Samarthan report.
Melghat did not have a full-time ITDP nodal officer for several years and it is only recently, after repeated strictures from the judiciary, that the government has finally appointed one.
Even when funds are allocated, there is little accountability on how they are used and Hatru's PHC is a prime example. The health centre lacks a toilet and does not have electricity owing to a defective solar plant.
While there was no effort to build a toilet or hire a mechanic to get the solar machine repaired, NRHM funds worth over `4 million were spent on a new PHC building at Hatru that has remained unused for close to two years since it was built, apparently because of a leaky roof.
Unicef's framework on malnutrition identifies disease and inadequate dietary intake as the proximate causes of malnutrition while political and social systems that determine how resources are used and shared are identified as the underlying or structural causes.
In Melghat, all of these factors seem to have conspired together to deprive children of a chance at a healthy life.
(This special report on malnutrition is the result of a fellowship jointly awarded by Save The Children and Mint. To know more about Save The Children: www.savethechildren.in)