Photos by Sudharak Olwe | Text by Priya Pathiyan

Malnutrition has recently been in the news owing to a number of reports divulging shocking statistics from India. Almost 882,000 Indian children under the age of five have died due to malnutrition in 2018 itself. The country ranked 102 out of 117 on the Global Hunger Index in 2019, which reported that around 90 per cent of children between the ages of six and 23 months in the country don’t even get the minimum food required. According to the National Family Health Survey 2015-16 (NFHS-4), stunting (low height for age) is prevalent among 38 per cent of children under the age of five, and the rate of wasting (low weight for height) of 20.8 per cent in the same age bracket is the highest in the world. And this is just the tip of the iceberg, as studies estimate that the situation will only escalate further in the years to come.

With 9.3 million children under the age of five affected by Severe Acute Malnutrition (SAM), India has the largest burden of severe malnutrition in the world.

But what exactly is SAM? Experts use the term to describe a condition that is current or recent, brought about by a decrease in food consumption resulting in wasting, loss of muscle, or oedema.

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There are two ways to treat SAM. One is facility-based, which means a local Anganwadi Worker (AWW) from the Integrated Child Development Scheme or an Accredited Social Health Activist (ASHA) — a community health worker from the Ministry of Health and Family Welfare’s National Rural Health Mission — will identify and refer a child suffering from SAM to the local Nutritional Rehabilitation Centre or Primary Health Care Centre. After running required tests to detect malnutrition, the child is admitted.

A SAM child is admitted for 14 to 21 days, and fed locally made F75 and F100 formula, which ensures a regulated calorie intake. After regaining a good appetite and body weight, the child is discharged and follow-ups through home visits are undertaken to check on the child’s continued well-being.

The second way is a community-based management of SAM, in which children without medical complications can be treated by feeding them Ready-to-use Therapeutic Food (RUTF), or other nutrient-dense food at home. It is believed that more than 90 per cent of malnourished children can be treated effectively using this method, but this hasn’t been the case in India yet, as the quality of RUTF has been questionable, and, in many cases, it’s not even available for distribution. However, despite the vast network of women working to bring about change — 1.28 million AWWs, 1.16 million AWHs. and more than 900,000 ASHAs — SAM continues to be a harsh socio-economic reality in the country, taking millions of children victim each year.

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Like little Rakesh, who lives in Munjal village in the Manpur area of Chhattisgarh, one of India’s most backward districts. Less than a year old, this Gond tribal boy bears all the signs of SAM – a distended tummy, the swelling of oedema distorting his body, his chest wheezing with pneumonia, absolute disinterest in his eyes and lethargy in his reed-thin limbs. Ever since his mother left the family to go back to her maternal home, he’s been looked after by his weary grandmother, who feeds him milk powder when she can afford it. His father works outdoors all day, and prefers to check on his son’s health while he’s asleep as he feels helpless.

Or then there’s the story of 18-year-old Shahnaz Parveen from the Muamari village in the Kharupetia area of Assam’s Darrang district. At two years and eight months, her son Aziz Ahmed is a SAM child, who's so weak that his legs don’t support him when he tries to walk. He also has a problem passing urine. Shahnaz was married at 15, and is now back in her maternal home, as her husband left her for a second wife and moved to Bengaluru. She hasn’t been able to consult the specialist in Guwahati that the local doctor recommended for Aziz, as the hospital officials there insist that the father’s signature is necessary to admit the child. Evidently, the involvement of parents is among the many reasons determining the healthcare provided to a child.

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Martina Topno, the Child Development Project Officer (CDPO) who's lauded as Manpur’s ‘Nutrition Warrior’ attributes the high incidence of SAM in the tribal areas to abject poverty, early marriages, as well as superstitious beliefs of the adivasis. “They liken their babies to the fruit of the custard apple tree. Just as some custard apples will fall to the ground and rot while others will flourish, they think it’s okay if they lose some children,” Topno says, adding that this fatalism is probably a result of sheer helplessness. She believes the only way forward is to create awareness through home visits and campaigns.

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The dynamic Jyoti Rekha Borgohain, who doubles up as the Child Development Project Officer (CDPO) as well as the District State Welfare Officer (DSWO) in Dibrugarh, Assam, agrees that such consistent messaging could only help if it reached the worst affected. She explains: “We work hard to spread the message of refraining from early marriages, providing nutrition for future and expectant mothers, spacing between pregnancies, breastfeeding for the first six months including regular feeds at night, but often, these are not the highest priority in a population with low income and educational status, like the Tea Garden Labourers (TGL). They are mostly migrant workers or from tribal communities, and often live in very remote villages. They do not have access to clean water or good medical care. Food scarcity hits them seasonally, and we usually see a rise in SAM cases when this happens.”

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It’s the marginalised populations everywhere that face the brunt of hunger politics, with religion and caste being instrumental in determining opportunity. For instance, the tribal communities of Warli, Mahadev Koli, Katkari and Thaker residing in Maharashtra’s Palghar district — a region that has emerged as the epicentre of the SAM crisis in the last 20 years. In 2015-16, there were 555 SAM-related deaths, while the following year saw 475 similar deaths of children in Palghar. Just like it is in other states, women here too work for up to 12 hours a day in fields and as landless labourers, leaving their infants in the care of older family members, or their older children. Many cannot afford to stay at home after delivery, and have to return to work immediately as they can’t afford to lose out on their daily wage, which means that their newborn babies cannot be exclusively breastfed.

Like 28-year-old Archana Karpade, who is at the Primary Health Care Centre at the village of Mokhada in Maharashtra, with her 14-month-old baby Ashwini, who weighs merely 6.2 kilos. Belonging to the Warli tribe, their family owns a small patch of land where they grow millet (nachni).

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Archana had to work in the fields through her pregnancy, missing out on essential rest and supplements. This harvest (kapni) season has been especially difficult for her as she had to work long hours leaving her daughter at home. Now Archana, like so many mothers across India, waits, as her child fights the long hard battle ahead to gain the target weight that will take her out of the dreaded SAM category, and put her on the road to recovery.

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