While Subhash survived, over half a million children die in India before their fifth birthday because of severe acute malnutrition, according to the Indian Academy of Paediatrics. One child dies every minute.
A majority of Indian children suffer from some form and extent of under-nourishment. According to the countrywide national family health survey, last conducted in 2005-'06, 38.4% of children in India under the age of three were stunted or too short for their age. Forty six percent of children were underweight and too thin for their age.
About 6% of the children suffer from severe acute malnutrition, which the World Health Organisation defines as very low weight for height and visible severe wasting. This has the highest risk of death compared to other forms of malnutrition, making it the primary factor contributing to child mortality in India. According to WHO, it is estimated that out of 19 million children suffering from severe acute malnutrition in all developing countries, 8 million are in India, twice than in sub-Saharan Africa.
Until recently, the Indian government had no clear policy to identify and treat such children. In 2011, the Ministry of Health published operational guidelines for "facility-based" management of such cases, which essentially means hospitalising a child.
Many experts, however, argue that treating malnourished children at home and in the community is more effective. According to Rajib Dasgupta, professor at Jawaharlal Nehru University's Centre of Social Medicine and Community Health, the primary problem with the facility-based approach for treating a severely malnourished child is that majority of children do not need to be admitted to a hospital.
“Uncomplicated severe acute malnutrition does not require government facilities," he said. "In complicated cases, where illness coexists with malnutrition, treating the illness is crucial, which requires good paediatric services that are not available at the government facilities.” He added that keeping a malnourished child in a hospital is difficult for poor parents since they stand to lose their daily wages.
In Africa, Médecins Sans Frontières has successfully implemented a model of community-based management of acute malnutrition. Based on its experience, it has started a similar programme in Darbhanga, Bihar. The deputy country director of MSF India, Dr. Prince Mathew, described it as "a way to treat acutely malnourished children in resource poor settings by providing them with nutrient rich therapeutic food regularly until they gain enough weight.”
Munni Devi wraps a colourful paper scale around Adit’s upper arm. Adit is eighteen months old. His arm’s circumference, little thicker that a two-rupees coin, is clearly at the lower end of the red part of the tape that marks severe acute malnutrition.
A social health worker of the government, Munni Devi visited Adit's home and identified him as suffering from severe acute malnutrition. This formed the first step in MSF's protocol. In the second step, she told Adit's mother to take him to the primary health care centre to obtain therapeutic food, which will help him gain weight.
Over last five years, since she was trained by MSF, Munni Devi has identified hundreds of such children – mostly girls and children of malnourished or pregnant mothers. Earlier, her training by the government focused on promoting breast feeding, sanitation and nutritious food eating practices among mothers under National Health Mission. “But daily wage work, severe undernourishment, frequent pregnancies among mothers often make regular breast feeding impossible," she said. "It is children of such women who get severely undernourished.”
Lalita Devi, Adit’s mother, for instance, was married at the age of 15. She is malnourished herself and her body barely makes enough milk for Adit, her fourth child. Adit was six months old, when Lalita Devi found that she was pregnant again, and her body stopped producing breast milk for the growing baby. Being brought up on chai and biscuit, Adit’s story, said Munni Devi, is typical of an acutely malnourished child.
Children like Adit who have "uncomplicated" severe acute malnutrition do not require medical treatment. The children can be treated with therapeutic food over couple of months given at the public health centre. Of the total number of children treated by MSF in Darbhanga, 90.7% of the cases were "uncomplicated".
But some undernourished children like Subhash develop symptoms like tubercular infection, cardiac heart diseases, respiratory disease or recurrent fever that require medical treatment. Social health workers trained by MSF refer such cases to Nutrition Rehabilitation Centre for minor complication and to the Malnutrition Intensive Care Unit in Darbhanga for major complications.
Involving the community
The thrust of community-based management of acute malnutrition is on preventing complications by identifying and treating acute malnutrition in the community. MSF’s project in Bihar has treated more than 17,000 children in the last five years. Other community-based projects are Maharashtra government’s Rajmata Jijau Mother-Child Health and Nutrition Mission and Orissa government’s pilot project in Kandhamal district with UK-based non-profit Valid International.
Comparing the three models, Dipa Sinha, an activist with the Right to Food campaign, points out that the MSF programme in Darbhanga is not strictly community-based. “MSF is not reaching out at community level to each village," she said, "and that's why the dropout rate is high compared to Maharashtra where each anganwaadi acts as touch points to detect and treat the cases."
But the government is yet to frame guidelines on community-based approaches to tackle malnutrition. "The subject has become a football between two ministries," said Biraj Patnaik, principal adviser to the Supreme Court commissioners on the Right to Food, referring to the Ministry of Women and Child Development and the Ministry of Health. "With nutrition listed under women and child development in the rules of business of Government of India, they are reluctant to cede space to the Ministry of Health."
Currently, government policies to tackle child malnutrition are fragmented across ministries. The Ministry of Women and Child Development limits itself to running anganwadis under the Integrated Child Development Scheme. The Ministry of Human Resource Development promotes the mid-day meal scheme in schools, while the Ministry of Health promotes breast milk.
The failure of the anganwadi and mid-day meal programmes explains the large extent of undernutrition among children in India, said Professor Dasgupta. To frame a policy to treat malnutrition would mean accepting this failure among many others.
Given the chronic nature of malnourishment in India, however, some experts believe the policy net needs to be cast wide to cover health care, sanitation, livelihoods, women’s empowerment. Focusing on severe acute malnutrition cases in isolation would not help. "Severe acute malnutrition is just the tip of the iceberg," said Dipa Sinha. India needs to focus not just on treating children like Subhash, but also preventing more children from being born as frail as him.