- By Dr. Isha Sharma
Highlighting the need of proper nutrition, Gabriela Mistral, a Chilean poet and humanist in 1948 quoted "We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. With only 9.6% of children aged between 6-23 months receiving adequate diet as per NFHS 4, nothing can be more disgraceful for a country then failing to provide enough food for its children.
India ranks 102 among 117 qualifying countries with 20.8% children being wasted and 37.9% stunted as per Global Hunger Estimates 2019. 7.5% children suffer from Severe Acute Malnutrition (SAM) as per NFHS 4 data, translating into 11.6% more chances of dying from preventable disease before reaching the age of 5 years in comparison to a healthy child.
To catch the low hanging fruits for reducing child mortality, it is imperative to focus on SAM children. Depending on the intensity, they are graded as medically complicated or uncomplicated. In 2011, the Government of India released a guideline for Facility-based management of SAM child. It suggests that for effective management, each district with a population of 2 lakh requires the provision of around 60 beds which can be placed as 20 in the district hospital and 10 in supplementary Nutrition Rehabilitation Center (NRC). 1151 NRCs have been established in India till now, as per Ministry of Health and Family Welfare, which translates into maximum 30 beds per district.
Out of 640 districts in India, only 51 have a population under 2 lakhs, rest of them are as high as 11,060,148 as in Thane, Mumbai as per census 2011 data. Given the numbers, it is evident that with the current resources, we cannot depend only on the facility-based care to manage and treat SAM cases.
A more sustainable and cost-effective way of management of uncomplicated SAM is through Community based management of acute malnutrition (CMAM), which involves timely detection of condition and the provision of treatment with energy dense nutritious food (EDNF) or locally available nutrient-rich home-based food. In the last decade, various such pilots have taken place in India, tried and tested different approaches to the CMAM model.
In India, CMAM was started as an emergency response in Bihar during the Kosi floods in 2009. This pilot was led by Médecins sans Frontières with support from the Bihar government where it successfully achieved a cure rate of 88.4%6 for non-defaulting cases. The success proved how a simple approach if implemented properly, can have a huge impact even in severe resource-constrained settings.
Few states like Gujarat, Rajasthan and Maharashtra are the prime example of states that have successfully adopted the CMAM approach and have addressed thousands of children who are suffering from SAM. The learnings and outcomes from these projects have guided government programs and civil service organizations to design and implement the most appropriate model as per the community needs.
With the presence of food diversity and traditional knowledge of home-based nutrition in India, every state can adopt its version of EDNF adhering to the standards as defined by the WHO. The states should not only focus on quantity of nutrients but quality of nutrients which EDNF will provide.
A study conducted by researchers from Public Health Foundation of India, in 2015 found out that more than 130 varieties of indigenous food, which were rich sources of micronutrients like calcium, iron, vitamin A, and folic acid were present in Oraon tribe of Jharkhand. This unexplored wisdom is present throughout India and if utilised properly with routine diet, it can provide the most cost-effective and sustainable solution for malnutrition. For the success of the CMAM approach, it is necessary to adopt a convergent approach with water and sanitation facilities, education, agriculture/ food security and livelihood. Though there have been initiatives for convergence as defined in the National Nutritional strategy 2018, the overall effectiveness is still unmeasured.
If India wants to become a USD 5 trillion economy as well as to grow sustainably to become one of the world forces to reckon with, it needs to focus on its future workforce, the children of today.
As mentioned by Oshaung et al in 1994 "Malnutrition causes a great deal of human suffering-both physical and emotional. It is a violation of a child's human rights". With the change in priorities and focus along with the change in governments, malnutrition has already reached the tipping point in India. The country is calling out to rescue its future generation and to provide them with the opportunity to lead a healthy and productive life irrespective of their socio-economic status. Only because these children cannot voice their right to food and healthcare themselves, only time will tell how much the government would listen to these indiscernible silent cries.
(Dr Sharma is a global health researcher and a current student of MSc Global Health Policy at the London School of Economics and Political Science, London, United Kingdom.)