Hidden Hunger

One child dies every minute of severe acute malnutrition. How can India save them?

The government is yet to frame policies on how to tackle severe acute malnutrition but non-profits have started experimenting with community-based models.

Nurses call him "the boy who lived." Severely dehydrated, unconscious and weighing no more than two kilos, lighter than a healthy new born, one-year-old Subhash was brought to the Darbhanga Medical College in Bihar in February. Admitted to Malnutrition Intensive Care Unit, he was administered glucose, therapeutic milk and antibiotics. It took him 40 days to open his eyes and cry lustily.

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.

Palak was found under a pile of soil and brought the Malnutrition Intensive Care Unit in Darbhanga. 



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.”
The MSF approach



The red part of the measuring tape shows severe acute malnutrition.


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.

Lalita Devi feeding therapeutic food to Adit


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."

India lacks clear policies on how to tackle cases of severe acute malnutrition


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.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Harvard Business School’s HBX brings the future of business education to India with online programs

HBX is not only offering courses online, but also connecting students to the power of its network.

The classic design of the physical Harvard Business School (HBS) classroom was once a big innovation – precisely designed teaching amphitheaters laid out for every student to participate from his or her seat with a “pit” in the center of the room from which professors orchestrate discussions analyzing business cases like a symphony lead. When it came to designing the online experience of HBX—the school’s digital learning initiative—HBS faculty worked tirelessly to blend these tenets of the HBS classroom pedagogy with the power of new technology. With real-world problem solving, active learning, and social learning as its foundation, HBX offers immersive and challenging self-paced learning experiences through its interactive online learning platform.

Reimagining digital education, breaking the virtual learning mold

Typically, online courses follow a one-way broadcast mode – lectures are video recorded and reading material is shared – and students learn alone and are individually tested. Moving away from the passive learning model, HBX has developed an online platform that leverages the HBS ‘case-based pedagogy’ and audio-visual and interaction tools to make learning engaging.

HBX courses are rarely taught through theory. Instead, students learn through real-world problem-solving. Students start by grappling with a business problem – with real world data and the complexity in which a business leader would have to make a decision – and learn the theory inductively. Thus even as mathematical theories are applied to business situations, students come away with a greater sense of clarity and perspective, whether it is reading a financial report, understanding why a brand’s approach to a random sample population study may or may not work, or how pricing works.

HBX Platform | Courses offered in the HBX CORe program
HBX Platform | Courses offered in the HBX CORe program

“Learning about concepts through real-life cases was my favorite part of the program. The cases really helped transform abstract concepts into observable situations one could learn from. Furthermore, it really helped me understand how to identify situations in which I could use the tools that HBX equipped me with,” says Anindita Ravikumar, a past HBX participant. India’s premier B-school IIM-Ahmedabad has borrowed the very same pedagogy from Harvard. Learning in this manner is far more engaging, relatable, and memorable.

Most lessons start with a short 2-3 minute video of a manager talking about the business problem at hand. Students are then asked to respond on how they would handle the issue. Questions can be in the form of either a poll or reflections. Everyone’s answers are then visible to the ‘classroom’. In the words of Professor Bharat Anand, Faculty Chair, HBX, “This turns out to be a really important distinction. The answers are being updated in real-time. You can see the distribution of answers, but you can also see what any other individual has answered, which means that you’re not anonymous.” Students have real profiles and get to know their ‘classmates’ and learn from each other.

HBX Interface | Students can view profiles of other students in their cohort
HBX Interface | Students can view profiles of other students in their cohort

Professor Anand also says, “We have what we call the three-minute rule. Roughly every three minutes, you are doing something different on the platform. Everyone is on the edge of their seats. Anyone could be called on to participate at any time. It’s a very lean forward mode of learning”. Students get ‘cold-called’ – a concept borrowed from the classroom – where every now and then individuals will be unexpectedly prompted to answer a question on the platform and their response will be shared with other members of the cohort. It keeps students engaged and encourages preparedness. While HBX courses are self-paced, participants are encouraged to get through a certain amount of content each week, which helps keep the cohort together and enables the social elements of the learning experience.

More than digital learning

The HBS campus experience is valued by alumni not just for the academic experience but also for the diverse network of peers they meet. HBX programs similarly encourage student interactions and opportunities for in-person networking. All HBXers who successfully complete their programs and are awarded a credential or certificate from HBX and Harvard Business School are invited to the annual on-campus HBX ConneXt event to meet peers from around the world, hear from faculty and business executives, and also experience the HBS campus near Cambridge.

HBXers at ConneXt, with Prof. Bharat Anand
HBXers at ConneXt, with Prof. Bharat Anand

Programs offered today

HBX offers a range of programs that appeal to different audiences.

To help college students and recent graduates prepare for the business world, HBX CORe (Credential of Readiness) integrates business essentials such as analytics, economics, and financial accounting. HBX CORe is also great for those interested in an MBA looking to strengthen their application and brush up their skills to be prepared for day one. For working professionals, HBX CORe and additional courses like Disruptive Strategy, Leading with Finance, and Negotiation Mastery, can help deepen understanding of essential business concepts in order to add value to their organizations and advance their careers.

Course durations range from 6 to 17 weeks depending on the program. All interested candidates must submit a free, 10-15 minute application that is reviewed by the HBX admissions team by the deadlines noted on the HBX website.

For more information, please review the HBX website.

This article was produced by the Scroll marketing team on behalf of HBX and not by the Scroll editorial team.