Budget 2018

To ensure proper nutrition for TB patients, give them food instead of cash, say experts

Rs 600-crore budget for nutrition support and aid of Rs 500 per month will do little to prevent undernutrition in TB patients, say public health specialists.

Direct benefit transfers may not be the best way to ensure that tuberculosis patients get essential nutrition, say public health activists, who are critical of such a provision in the budget.

Finance Minister Arun Jaitley announced in his budget speech that the government would allocate Rs 600 crore for the coming financial year for nutritional support of tuberculosis patients. This, he said, will ensure that all tuberculosis patients in India get Rs 500 every month for their nutritional needs for the duration of their treatment.

The announcement is in line with the Revised National Tuberculosis Control Programme’s National Strategic plan for up to 2022, which states that the programme will provide a monthly support of Rs 500 via direct benefit transfer to all patients “to incentivise treatment completion”. However, a guidance document on nutritional care and support of tuberculosis patients in India drawn up last year by the Central TB Division, the Ministry of Health and Family Welfare with support from the World Health Organisation recommends distributing protein-rich food baskets as nutritional support. The document provides operational guidelines to implement such a scheme and does not mentions direct benefit transfer.

“Direct benefit transfer is a political decision and may not really help patients,” said Dr Yogesh Jain, a paediatrician in Chhattisgarh and founding member of the public health non-government organisation Jan Swasthya Sahyog. “It is for the optics, if they are serious, they should provide actual food.”

Jain argues that Rs 500 a month is too little for adequate nutrition for a person recovering from tuberculosis, given that the disease is closely linked with poverty in India. “The problem is that the food ration being given to a TB patient will be shared by the family so it will get diluted,” he said. “Hence, it is better to give them a food basket with adequate items to meet the nutritional support [of the family].”

Jain has been instrumental in framing the Chhattisgarh government’s nutrition programme for tuberculosis patients, in which the state distributes food baskets to patients for eight months. The programme, which was launched last year, costs the Chhattisgarh government about Rs 800 per person.

In contrast, under the Centre’s proposal of cash transfers of Rs 500 per patient, given the highly fluctuating costs of food grains, pulses and eggs, there is no guarantee that a patient will get their required amount of protein. According to Jain, a direct benefit transfer might ensure that a tuberculosis patient buys three eggs and nothing else. “But that is not enough to even meet the protein requirement,” he said. “A healthy person requires 50 to 60 grams of protein every day. And what about calories? It would have been better if the government provided for food baskets which ensures that the patient gets the right quantity of food items which can help increase the protein intake.”

The group of doctors and dieticians who drafted the guidance document recommended that TB patients should be given food baskets, their ration from the public distribution system be enhanced and they should be provided with daily multivitamin supplements.

Some officials at the Ministry of Health and Family Welfare insisted that cash transfers were more practical than providing food. “The health ministry is responsible for providing diagnosis and treatment,” said Sunil Khaparde, deputy director general for tuberculosis. “We cannot start providing rations to patients as it requires a different infrastructure, which the health ministry does not have.”

The argument stands at odds with the Modi government’s claims of inter-ministerial collaboration.

At the same time, Manoj Jhalani, additional secretary at the health ministry, said that the Centre would let state governments decide how to provide nutrition support. “It can be either cash transfer or kind,” he said.

Pilot projects

The nutritional support under the Chhattisgarh programme is tailored to patients with drug sensitive tuberculosis for whom the treatment lasts between six and eight months. However, a drug resistant TB patient has a longer treatment schedule lasting at least 24 months. Chhattisgarh government has said it will extend the nutrition support to such patients over longer durations as long as the budget is adequate. “We have the budget to provide nutritional support for this fiscal year,” said Dr Madhav Rao Deshpande, the state officer for the TB control programme. “We want to provide the food packets to all patients throughout the treatment, depending on the budgetary provisions.”

Mumbai’s municipal corporation is also planning to kick off a programme to provide nutritional support to tuberculosis patients. “We will be providing a nine kilo food packet to TB patients [every month] which will consist of grains and pulses,” said Dr Daksha Shah, Mumbai’s TB officer. Dr Shah said that the contents of the food basket have been fixed in a way that the patient gets at least 30 grams of protein every day. Shah said that the corporation did not consider giving cash aid because it may be misused. “We really can’t tell what the patient will buy from the money we give them,” she said.

The Municipal Corporation of Greater Mumbai has earmarked Rs 13.50 crore in the budget this year to pay for the nutritional scheme that is expected to benefit close to 25,000 TB patients.

Jain said that the past experiences within India and abroad have shown that distributing aid in kind is beneficial for TB patients. “Even Haiti and Vietnam have provided food for TB patients and it has helped,” he said.

Wrong perspective

Tuberculosis and undernutrition are part of a vicious cycle. Undernutrition impairs immunity and predisposes to development of tuberculosis. Tuberculosis in turn leads to significant undernutrition which in turn worsens severity of tuberculosis, and increases the risks of a number of serious outcomes including death.

“Given the severe undernutrition in TB patients, nutritional support is an essential part of TB care,” said Dr Anurag Bhargava, professor of medicine, Yenepoya Medical College in Mangalore.

According to the results of a large study which Bhargava coordinated in rural India, the average weights of men and women were only 42 kg and 34 kg respectively, while according to Indian Council of Medical Research, the weight of a healthy Indian man or woman should be 60 kg and 55 kg respectively.

Further studies have shown that weight gains in Indian patients are poor because of an inability to afford a diet adequate in calories and proteins. This means that even at the end of treatment, patients are most often underweight and are between three and four times higher risk of recurrence of disease. Even in patients with serious forms of drug resistant tuberculosis, survival is linked to body weight and is three times higher in those above 50 kg.

According to Bhargava, a tuberculosis patient who weighs more than 50 kg is three times more likely to survive compared to a patient who weighs less than 50 kg.

Moreover, undernutrition in adults is the major driver of the epidemic in India, and 55% (or more than a million) of new cases were attributable to its effects, according to a 2014 study by Bhargava and others.

“We, as a country, need to closely look at addressing the problem of undernutrition which is responsible for spreading TB and hinders the treatment outcomes,” said Bhargava.

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.