Malnutrition has come back to Hosanagara in a severe acute form

• Let’s know about Hosanagara firs

Hosanagara is a Taluk of Shimoga (Shivamogga) district in Karnataka. According to the 2011 census, it has a population of 118148 within which 58503 are male and 59645 are female. It comes under the hilly zone (Shimoga has been divided into two agro climatic zone according to their situation) of Shimoga district. Paddy, pulses and areca nut are the major crops that are grown in this zone. According to the 2011-12 report, the geographical area of Hosanagara is 142279 hectares; forest occupies 35027 hectare land of that. Apart from barren and non-agricultural land, the cultivated area is 19548 hectares.

The number of hospitals in the entire Taluk is one along with 10 Primary Health Centres(PHCs). They are running out of doctors and medicines. Children eat only carbohydrate foods like rice without any other supplementary food. Their hygiene is very poor;  worms attack their body every now and then. Children mostly suffer from malnutrition, anemia, calcium deficiency and other heart-lung related disease as a reason of under nutrition. Another concern is that of Severe Acute Malnutrition among children (SAM children), which, according to WHO (World Health Organization), is a type of Malnutrition.

Cervical Palsy and Defect at birth is also common as mothers suffer from malnutrition and anemia. Vitamin A, D deficiency is very common in most of the children. The number of severe cases has gone down but fatal cases are increasing among children between the age limits of 0-3.

World Health Organization says about SAM:

According to the World Health Organization the definition of Malnutrition is, “It refers to deficiencies, excesses or imbalances in a person’s intake of energy and/ or nutrients. The term malnutrition covers 2 broad groups of conditions. One is “under nutrition”- which includes stunting (low height for age), wasting (low weight for height), under weight (low weight for age) and micronutrient deficiencies or insufficiencies ( a lack of important vitamins and minerals) The other is overweight, obesity and diet related non communicable diseases ( such as heart disease, stroke, diabetes and cancer).”

Malnutrition has different types with respect to their seriousness. According to WHO, the guideline to identify a SAM child is: 1. “Health workers and members should measure the mid- upper arm circumference of infants and children who are 6- 59 months of age and examine them for bilateral pitting Oedema. Infants and children who are 6-59 months of age and have mid upper arm circumference <115 mm, or who have any degree of bilateral Oedema should be immediately referred for full assessment at a treatment center for the management of severe acute malnutrition.

In primary health care facilities and hospitals, health care workers should access the mid upper arm circumference or the weight for height/ weight for length status of infants and children who are 6- 59 months of age and also examine them for bilateral Oedema. Infants and children who are 6-59 months of age and have a mid upper arm circumference <115 mm or a weight for height / length <- 3 Z scores of the WHO growth standards, or have bilateral Oedema, should be immediately admitted to a program for the management of severe acute malnutrition.”

• Story of Sanvi, a SAM child

Sanvi has just turnedone, five months ago. She has already developed respiratory problems and the doctor has asked her mother to let her practice breathing exercises. She is the daughter of Sruti and Chandrappa. She is not as cheerful as children of her age and often gets tired very quickly. Also, doctors have detected that she is suffering from congenital pulmonary venolobar syndrome which is a rare heart disease. She comes to the nearby Anganwadi regularly where the teacher, Vatsala, helps her to have food and medicine.. She is very close to her mother because Sanvi’s father left the mother before she was even born. While asking her mother about her situation, she wiped her eyes. She married her blood relative. Medical sciences suggest that marriage among blood relatives result in genetic deficiencies among children.  According to the doctor’s prescription, in 1 year 5 month of age, Sanvi is under weight. She is only  six kg.  She is under weight because her mother was not taken care of, during her pregnancy.According to the World Health Organization (WHO) limits, Sanvi is a Severe Acute Malnutrition (SAM) child.

According to the available data from the Taluk office, the total number of Anganwadis in the Taluk is 345, total number of working teacher is 345, and helper is 206. The main Anganwadi centre is 206 and mini Anganwadi is 139.

Sriramnagara Anganwadi, where Sanvi is getting treated, has many other children who are either in severe or in moderate condition in terms of Malnutrition. Teacher Vatsala said about Sanvi, “She has low mid arm circumference and low weight. Along with that her limbs are also swelling. In medical terms, doctors call it Oedema. Doctors  have suggested a surgery for her Congenital pulmonary Venolobar Syndrome. As she is a SAM child,  it is risky to operate her until she gains proper weight. Now she is taking nutritious food.”

Her daily diet now consists of pulses and boiled vegetable which Saroja, the helper of that anganwadi center gives her every day. Sruti, Sanvi’s mother is also anemic. She feeds her baby breast milk though. Sanvi is prescribed to have an egg per day, 5 days per week.

There are many children like Sanvi in Hosanagara, who are suffering from Severe Acute Malnutrition which is leading to major health concerns.

Malnourished children category does not end with SAM children:

Not all severe babies are SAM. In Hosanagara, currently, the number of severe malnutrition babies is 35. The Anganwadi teachers are identifying children who are under nourished. Asha workers and Anganwadi workers are supposed to go to people’s home but sometimes due to salary hike protests they are not found doing their work properly.

Now, the Karnataka State Government is providing IFA (iron tablets) in schools and syrup in the Anganwadi. They are also providing milk and eggs to Anganwadis, since April. This is a move that has been in operation in school for three years, now.. A team of four doctors, two staff nurses visit the most under developed areas to take records of incidents under the Rashtriya Bala Sasthya Karikrama Scheme, which is a central government scheme. The Karnataka government, meanwhile, has schemes for mothers and children. After delivery, every mother gets a stipulated amount of money under the state government’s Janani Suraksha Yojana (JSY)

Swara is 2 years old. She was detected as a SAM child.  However, now, Swara consumes essential nutrients because of which she has been recovering.  She had periodical diarrhea.  Doctors stated that unhygienic livelihood and food habits to be the reason of her disorder.  She was advised normal food diet, breast feeding and special care. Her Anganwadi teacher Vanaja said, “We need to spread awareness about sanitation and hygiene among parents as infection spreads very easily.”

Susma, mother of Swara who takes her to the Anganwadi daily is happy as doctors have told her that her child is recovering quickly.

Vanaja is maintaining 45 children, single handedly.. She said, “. We need to go door to door, with tapes to measure the babies. Then we need to inform the doctors. We feed the children. Sometimes mothers do not want to come. We need to counsel them to come for the betterment of their child.

Almost all Anganwadi has only one teacher with one helper. Some does not have any helpers. The teacher to child ratio is 1: 40 on an average. In answer to how difficult it is to manage so many children alone Vanaja said, “It is difficult but this is how the process is.”

Dr. Pravuswami F. M, RBSK medical officer said, “Girl child are still neglected here because if we see the data, mostly girls will be found undernourished.”

Problems are widely spread

• Anemia and Motherhood

Talking about the condition of pregnant women in the Taluk, Dr. Lingaraja G B, the only doctor in the Hosanagara taluk hospital said, “Anemia is very common in women here. They do not consume proper food during their motherhood also. Rice is the only food they consume. So, they run out of balanced diet and that affects the child in their womb. Low weight birth is very common in this area. That is one of the reason which leads to malnutrition here.”

According to IOSR-JNHS report, Anemia is a major health problem in Karnataka, especially among women and children. Anemia can result in maternal mortality, weakness, diminished physical and mental capacity, increased morbidity from infectious diseases, prenatal mortality, premature delivery, low birth weight, and (in children) impaired cognitive performance, motor development, and scholastic achievement. The report says, in Karnataka, 70 per cent of children between the ages of 6 and 59 months are anemic. This includes 29 percent who are mildly anemic, 39 percent who are moderately anemic, and 3 percent who suffer from severe anemia. It is expected that an anemic mother is prone to give a birth to man anemic child.

Tejaswi B T, doctor of Nagara PHC said something similar to this and said,, “I receive women patient who are mostly anemic. If one does not consume proper food, medicine also does not work. We find malnourished children as they do not get proper nutrition from their mother.”

• Villagers and their food habits

Social worker and health visitor of Hosanagara taluk, Sudhanagara LHV said, “In adolescent period, girls do not get proper food. They become anemic. When they become mothers, the child gets affected.”

According to Dr. Sajni Shetty, Rastriya Bala Sastha Karikrama(RBSK), Hosanagara, “Food habits are very poor in this area. They only eat rice which means they only consume carbohydrate. Poverty hits hard in this area because people have less work and more people to feed. Human being ,especially during pregnancy, women need a balanced diet which they do not have here. Women here work during their ninth month of pregnancy and ends up giving birth to either low weight child or a child which is defective  at birth. If the mother is not eating properly after giving birth to a child she can’t breast feed her child? Breast feeding is very important for the infants.”

“Anganwadis are there but awareness among people are not there. Some have social issues and some face family problems. There are also other reasons for under nourished children “she added.

Dr. Lingaraja G B also agreed to the fact by saying, “The food habit is a cause of suffering for people here. They do not know what is called a balanced diet. If you look at the mid day meals you will find children having rice and sambar which is not enough for a growing up child.”

To get to know about the general food habit of different ages and people of different profession, a random survey helped.

The chart shows an average food habit of the villagers supporting to the statement of the doctors that the villagers are not aware of what is a balanced diet and to be fit and fine what foods need to consumed.

• WHO has to say about Balance diet:

According to WHO, Balanced diet for an adult contains, Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice), at least 400 grams (5 portions) of fruits and vegetables a day. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables. Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, canola and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard). Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not a part of a healthy diet. Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use iodized salt.

WHO and NHP India which is National Health Portal of India suggest extra care for the pregnant and lactating mother. For them, other than proper food, “micronutrients (like folic acid/ iron tablets) are specially required in extra amounts to reduce the risk of malformations in baby and increase birth weight of baby and to prevent anemia in expecting mothers.Extra intake of Calcium is requiredfor proper formation of bones and teeth of the baby, for secretion of breast-milk which is rich in calcium and to prevent osteoporosis in the expecting and lactating mothers. Vitamin B12 and C are also needed to be taken by lactating mother.   Iron is needed for hemoglobin synthesis, and to provide immunity against diseases. Deficiency of iron leads to anemia and increases maternal mortality and low birth weight infants.”

PDS System and its fault:

There are various reason why the problem of under nutrition persists. Most of the people, who do not work on fields, have no work there. A large number of people are registered under the Below poverty level (BPL) card. But according to the villagers, from many months they are not getting food out of their cards. Wilson Gonsalves, a small pan shop owner, residing at Hosanagara for decades, said, “Earlier I had BPL card but now for some government issue I am not getting food out of that card. I went to the Gram Panchayat thrice but got no solution.”  Like Wilson, Rudrama has the same issue with her card. “Are you from the Panchayat? Can you tell me when I will get rice from the society?” she asked as she has three children in her home to feed.

While villagers are complaining about getting food grains from the society, CDPO officer T. Raju confidently said, “We have 345 Anganwadis in total where we provide rice, wheat, dal, milk, sugar, salt etc. There is no shortage of food.”

• Schools and mid day meals:

Holy Reedemar School which is a Kannada medium government school for class 1- 7, children get Sambar and Rasam as mid day meal. There is no system of providing eggs from the government in the mid day meal. Government provides milk powder which the children do not like to eat and gets wasted.

Head Mistress Rubina D’souza said, “If the government would have provided milk instead of milk powder, children would drink that.”

Sushma Srinivas Rao, a mother and HIV counselor of Hosanagara Taluk hospital said, “Children, in mid day meal do not get proper healthy food here. Patients who come to me are mostly anemic.”

• Are the government schemes reaching to them?

Doctors and people said that the Mathru Poorna Scheme, which is meant for pregnant women, has not been very successful as the women have to go to Anganwadi to eat a meal per day. Sometimes they do not go because of their physical condition. Sometimes they avoid going because they have family issues and other children to look after. Some villages are very interior and there is less communication system.

According to government norms, pregnant and lactating poor women in rural areas will get one nutritious meal daily for 25 days in a month. While inaugurating the scheme, according to reports, Chief Minister Siddaramaiah declared that the beneficiaries will get full meal, consisting of rice, dal with vegetables/sambar, one boiled egg and 200ml of milk, will be given to pregnant women. Those who don’t eat eggs would be given two varieties of sprouts and each meal is estimated to cost around 20 rupees. The food will be provided for 15 months, from the start of pregnancy up to six months after delivery.

While asking T Raju, Child Development Project Officer said, “We are providing food to women for full 9 months of pregnancy and post giving birth till 6 months.

According to available data from taluk office, they have enlisted 1800 women to this scheme since 2^nd October 2017 till date and provide the foods listed below:

But according to their words, they are not sure whether everyone is able to come to have the food they asked for under the scheme. So the mother, during pregnancy, is not getting proper food and then gives birth to a low weight child which results in the child to be under nourished.

Many schemes are there in pen and paper like Mathru poorna ,Stree saktiYojana, Udyogini scheme, Mathru bandhan, Bhagya lakshmi Yojana for women.

• Problem is hitting nationwide:

According to a recent news report based on National Family Health Survey (NFHS), the total number of SAM children in India is over 93 lakh who require admissions in the NRC (Nutritional Rehabilitation Centers). The Report also claimed that during the year 2015-16, out of the 1,72,902 children enrolled in the NRCs, 92,760 were able to successfully recover from the above mentioned conditions. India’s rank in Global Hunger Index falls every year and the problem never gets resolved. In 2016, India was standing at 97th position among 118 countries with respect to the Global Hunger Index. In 2017, the report says India’s position fell by 3 positions and now stands 100th among 119 countries, even below the BRICS countries (Brazil, Russia, India, China, and South Africa.) The condition of India is deteriorating with respect to poverty, hunger, and malnutrition. Global Hunger Index (GHI) is a statistical tool to measure the hunger situation of different countries in the world. The index has been developed by International Food Policy Research Institute (IFPRI). They measure the rate of malnutrition of children in each country. According to the report of National Family Health Survey 2015-16, Three points of concern for child malnutrition in India is “firstly the availability of solid food with breast milk for young children (when they transition from exclusive breastfeeding) declined from 52.7% to 42.7%, secondly  the proportion of children between six and 23 months who received an adequate diet was 9.6%, thirdly no more than 48.4% of households had access to improved sanitation facilities; sanitation is an important factor in improving nutrition.” Sanitation and the distribution of food in India is a major drawback. Here food grains get destroyed in cold storage. Poverty cannot be controlled if the management of the system is not perfect.

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• Conclusion:

People are not aware of the schemes that government has arranged for them. Some schemes are not reaching them because of the lack of proper planning. Not only government schemes, Taluks need more doctors and hospital facilities to treat their patients. But the problem should be treated from the grass root. Lack of awareness among the people about food and hygiene fails to remove malnutrition from the country. So the solution should start from educating people to giving proper medical facilities to them.