Before the nationwide Covid-19 lockdown was announced on March 24, at least 96 children from a slum in Trombay, Mumbai, would visit Sangeeta Kamble’s anganwadi centre every day.

Even though the centre is run from the cramped home of a slum resident, Kamble tried her best to juggle all the duties of an anganwadi worker: providing hot meals and dry rations to children below six, measuring their height and weight regularly, scheduling mandatory vaccinations for them and serving as their pre-school teacher.

Since the lockdown began, however, the anganwadi has been shut and Kamble and her assistant have been “working from home”. For them, this has involved making regular calls to the children’s parents, watching half their slum empty out as migrant families returned to their villages, and trying in vain to arrange for nutritious rations for those who remained. Even though manufacturers of these nutritious “take-home rations” for children were supposed to continue their supply to anganwadis, Kamble claims all the anganwadis in her area did not receive any.

Kamble still calls as many parents as she can, asking after the health of the children and reminding them to get them vaccinated at rural health centres whenever they get the chance. But with no clarity on when her anganwadi will re-open, she has been growing anxious.

“The children have not received their take-home rations for three months. They have missed out on their vaccines,” said Kamble. “We have worked so hard to fight malnutrition in our slum, and now it is all going in reverse.”

Kamble’s fears echo those of thousands of anganwadi workers across Mumbai, the biggest Covid-19 hotspot in the country.

Established under the central government’s Integrated Child Development Services scheme, rural and urban anganwadis have been at the heart of India’s efforts to tackle child malnutrition for the past 45 years. Anganwadi services have been plagued by a range of problems – inadequate funding, corruption in the provision of rations, devaluing of women’s labour – but they have still carried on.

But with the pandemic, for the first time, anganwadis across India have almost completely shut down. In cities like Mumbai and Delhi, they may not re-open for several more months. This could leave lakhs of children from low-income communities more prone to malnutrition and more vulnerable to communicable diseases.

Vaccination dilemma

One of the key roles of an anganwadi worker is to record every pregnancy and birth in her area, draw up immunisation schedules for each child and ensure that they are vaccinated on time. The Covid-19 lockdown disrupted these schedules for over three months in Mumbai, but immunisation efforts restarted in several small health clinics in mid-June.

Anganwadi workers like Kamble in Trombay and Nirmala Bhonsale in Thane have now been calling up parents of every child who missed out on vaccines, urging them to visit local health clinics with their children.

“But parents are terrified of going to public clinics and I don’t blame them,” said Bhonsale, who manages an anganwadi in Thane’s Bhaiyapada slum north of Mumbai. “We have heard of many cases of nurses and doctors catching coronavirus. How can health clinics be considered safe for children?”

Bhonsale claims she has tried convincing nurses to visit her slum and go door-to-door to administer vaccines. “But nurses are so busy with Covid cases, they cannot come,” she said. “Because of all these problems, vaccination will be delayed even more for these children, and I feel that some children will be completely left out.”

AR Sindhu, the general secretary of the All India Federation of Anganwadi Workers and Helpers, points out that the situation is similar in many parts of rural India as well. “There are places where vaccination efforts did not completely stop during the lockdown, but often, anganwadi workers were involved with Covid work, and many anganwadi centres were being used as quarantine centres,” said Sindhu. “Because of this, many parents have refused to take their children there for vaccinations, and they have been left out.”

Some villages, like Rana Bordi in Gujarat’s Porbandar district, take pride in the fact that they have managed to catch up on vaccinations for all their children since immunisation restarted in the beginning of June.

“For three months we could not do anything, but in the last three weeks we have finished doing tikakaran [immunisation] for all the children who had missed out,” said Nimuben Gohil, a worker with one of the two anganwadis in Rana Bordi that serve nearly 150 young children.

The migrant exodus from cities to villages, however, has made it harder for anganwadi workers to track vaccination records and ensure that no child is missed out.

A measles flare up?

In April, soon after the lockdown began, an analysis of data from the centre’s National Health Mission revealed that at least one lakh children did not receive their BCG vaccination for tuberculosis in March, and at least two lakh children missed out the pentavalent and rotavirus vaccines that build immunity against meningitis, pneumonia, diptheria and tetanus, among other diseases.

The data also revealed a 34% drop in the number of measles vaccines administered across India between February and March, and a 69% drop between March 2019 and March 2020. Since the measles vaccine must be given to a child between nine and twelve months of age, the numbers suggest that a large number of babies may have missed out on timely measles vaccines.

According to epidemiologist Dr Jacob John, a delayed vaccine dose will not reduce the effectiveness of the vaccine given to a child, but it could place the child at a greater risk of catching diseases. “I am worried about those missing the measles vaccine, because measles season is from January to April,” said John. “If there was a gap in the immunisation of children during the lockdown [in March and April], measles could flare up badly.”

Dr Vandana Prasad, a community paediatrician, said she has not come across reports of measles cases increasing in any part of the country. “But it is possible that we would not come to know of if they did, because regular health services have been affected by Covid-19,” said Prasad.

In Mumbai, Kamble is also worried about babies born during the lockdown who missed their tuberculosis vaccine, which is usually given immediately after a child’s birth. “All the slums in this area, stretching from Kurla to Mankhurd, have a lot of TB cases, so it is important for babies to be protected as soon as they are born,” said Kamble, who claims there is also no way for her to know whether any child in her area has contracted tuberculosis during the lockdown. “TB symptoms are similar to Covid, so no family will reveal if there is a new TB case.”

Unmeasured malnutrition

Besides spread of diseases that public health workers have fought hard to control, anganwadi workers are also worried about an increase in child malnutrition in the wake of the lockdown.

At anganwadis across the country, children between age three and six are provided with one hot cooked meal every day, and babies and toddlers are provided with “take-home rations” – dry, ready-to-cook food mixes that are required to be fortified with specific micronutrients to tackle malnutrition.

The quality of take-home rations has been notoriously poor in many states, and their manufacture and distribution has been mired in corruption for several years. But with the Covid-19 lockdown, the supply special take-home rations for children stopped nearly everywhere.

“Many people lost their jobs and income during the lockdown, so the government has focused on providing general dry rations instead, like rice and dals,” said Bhonsale, who has made sure that government rations sent once a month to her area have been distributed among the families whose children attend her anganwadi. “But those rations are shared by the entire family, and young children are not getting the special food they need.”

In Uttar Pradesh’s Varanasi district, anganwadi worker Asha Devi says that her village of Domari was not able to start supplying take-home rations for children and pregnant women until mid-May. “Now we go door-to-door to supply rations once a month,” said Asha Devi.

Like many other anganwadi and health workers across rural India, she has been spending more of her time on Covid-19 duty. “We check all the migrants who have returned home if they have symptoms, we maintain records about them and have to provide them with dry rations,” she said.

According to reports that AR Sindhu has received from members of her federation, the general supply of dry rations has been irregular. “In parts of Uttar Pradesh, Chhattisgarh and Jharkhand, families have not received any rations at all. This is bound to lead to a lot of malnutrition,” said Sindhu.

According to Bhonsale, the impact of the lockdown on nutrition can only be measured after anganwadis re-open and workers are able to record children’s weight and height again. “But in slum areas where anganwadis are run out of people’s one-room houses, we have no idea when we will re-open.”

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.