Malnutrition in Madhya Pradesh - An Overview

Thousands of children are languishing and sinking closer to starvation deaths in Madhya Pradesh. The National Family Household Survey (2006) put the number of malnourished children in this central Indian state at a whopping 6 million which is over 60 per cent of its total number of children under 5 years of age. Out of these 6 million malnourished children, 1.3 million have Severe Acute Malnutrition (SAM) and another 1 million have Moderate Acute Malnutrition (MAM). The situation is nothing short of a full-blown crisis that the Global Hunger Index places Madhya Pradesh between Chad and Ethiopia in its list of the world’s worst malnutrition ratings.

While government departments are trying to downplay the severity and evade criticisms, reports of deaths due to malnutrition sporadically surface in the media while many deaths go unreported. Though malnutrition is pervasive across the country, which has an estimated 200 million underweight children at any given time, Madhya Pradesh remains the most affected state. MP’s infant mortality is still one of the highest in India, with 72 out of 1000 children dying every year. At this rate, an estimated 130,000 children die every year in this state!

Malnutrition is one of the most serious and large scale health problems facing India in general and Madhya Pradesh in particular. Malnutrition constitutes 22% of the country’s disease burden because it severely weakens a child’s immune system, raising their mortality rates from common diseases such as pneumonia, malaria, measles and diarrhea. Children with SAM have extremely high mortality rates – between 20-30% - a rate of death approximately 20 times higher than well-nourished children.  A recent report estimated that 37% deaths registered between 0 to 4 years in Madhya Pradesh were due to chronic hunger and malnutrition. It is found that backward classes especially Scheduled Castes (SC) and Scheduled Tribes (ST) are the worst affected in the state. Incidentally, these two communities constitute a sizeable chunk of the state’s population. Tribal communities in MP are the most rural and marginalized communities in the country, having almost zero access to any health services and also the worst development indicators in the country. Scheduled castes, another major component of state’s population, as a collective, have a history of indigence and marginalization – both precipitating conditions for malnutrition.

Unfortunately, not much improvement is visible on the ground even after the commencement of many government schemes. The condition is sure to worsen further with the spectre of a drought looming large due to the capricious monsoon and insufficient rains during the sowing season. With the predicted steep decline in agriculture output this year and severe shortage of food in rural areas, suffering of children will only escalate. Unless the government and voluntary agencies do not work concertedly and spiritedly, the future of millions of children will remain in jeopardy. For, the millions of malnourished children who do survive childhood will be forever affected by malnutrition and their immune system will be seriously weakened.  This means children who have been malnourished in the first 5 years of life will have limited mental and physical growth capacity as compared to a well-nourished child. Malnutrition can have serious effects on the body of the child as it can stunt the normal growth of children and cause children to be underweight for their age. It can also lead to wasting or severe weight loss and can cause severe deficiency in key vitamins and minerals, such as anemia, or iron deficiency. There is evidence that a malnourished child will someday have children with low birth weights, perpetuating the cycle of malnutrition. Therefore, it becomes even more urgent to break this vicious cycle of malnutrition.

The dangerous coping mechanism of tribal communities of Tikamgarh for addressing the severe shortage of food and sources of nutrition is a good example of the severity of malnutrition in Madhya Pradesh. The Adivasis of Tikamgarh in Madhya Pradesh are always on the move. Their web of activity revolves around the pond in the village, where one finds ample ‘Samai’ grass. The people of the village collect the wild Samai grass in big quantities and dry the grains from the grass to make it into flour. This flour is used to make themselves ‘rotis’. This wild grass has become popular among the villagers for long, not because the grass is their traditional food or nutritious enough, but because; it is a substitute for food. It is this wild grass which extinguishes the burning sensation caused by hunger. The starving villagers keep ample of this grass in their homes. This is despite the fact that its consumption causes many life-threatening diseases.

Pockets of malnutrition deaths, have surfaced regularly in the state of Madhya Pradesh in the past seven months. The state stands testimony to the fact that about 55% of the children here are malnourished and there have been 169 malnutrition deaths, within such a short time span. As usual, the state government authorities never acknowledge that the deaths have been due to malnutrition. They are always, quick and prompt in declaring that the deaths have been due to malaria or measles or diarrhea.

Malnutrition in MP:  Recent News

News about deteriorating malnutrition condition of rural areas, especially the tribal areas, have been frequently appearing in the media. There have also been regular news reports on the failing institutional nutrition support services. However, state government has been in the denial mode attributing all deaths to various diseases. The National Commission for Protection and Child Rights chairperson, Ms. Shanta Sinha blamed the state government for gross malnutrition and subsequent deaths on 21 January 2012. She had called for greater decentralization for monitoring of malnutrition cases. It is estimated that 89% of the population in Madhya Pradesh does not receive adequate nutrition and almost 55 lakh children in the state suffer from malnutrition!

Representatives of non-government organisations on various platforms have claimed that severe malnutrition has claimed the lives of around 125 children under six years of age in four districts (Satna, Khandwa, Shivpuri and Sheopur) of Madhya Pradesh since May 2008. However, state government maintains that the child deaths were unrelated to malnutrition and were caused by diseases like pneumonia, viral fever and diarrhea. According to a petition filed recently in the Supreme Court by Right to Food Campaign, 64 Bhil tribal children have died of malnutrition in Satna district within the past four months. Similarly, Spandan, which works among the Korku tribe in Khalwa block of Khandwa district, has reported deaths of 39 children. The Saharia Mukti Morcha, which works with the impoverished Saharia tribe in Shivpuri and Sheopur districts, said 16 children had succumbed to malaria in Shivpuri and five in Sheopur over the last few days, because their immunity was destroyed by severe malnutrition. In 2009, Asian Human Rights Commission (AHRC) said that 80 percent of children in the Rewa district of Madhya Pradesh were affected by malnutrition and most of them belonged to the Kol tribe. Government data on both malnutrition and deaths resulting from malnutrition is unavailable. In any case, the natural response of the government to deaths of children is to attribute these deaths to diseases than malnutrition.

Unicef, which has worked extensively on improving nutrition supply systems of the worst affected districts of Madhya Pradesh, observed the seriousness of malnutrition condition of Madhya Pradesh and said in one of its reports that the prevalence of malnutrition varies across states, with Madhya Pradesh recording the highest rate (55 per cent) and Kerala among the lowest (27 per cent).

Areas of High Prevalence of Malnutrition in Madhya Pradesh

Nearly all areas of Madhya Pradesh are affected by malnutrition but not equally. The incidence of malnutrition is more serious in tribal dominated districts and areas that have been under livelihood insecurity for extended periods of time. Recent statistics prove that tribal dominated areas need urgent attention as these areas have also witnessed severe livelihood and nutrition insecurities. In most cases, these tribal dominated districts are also the least developed districts of Madhya Pradesh. The most affected districts of Madhya Pradesh, in terms of the number of deaths and the news coverage, are Satna, Rewa, Khandwa, Jhabua, Shivpuri, Sheopur, Chhattarpur, Mandla, Badwani, and Alirajpur. One of the distinct characteristics of these seriously affected areas is that these districts have significant population of tribal communities.

Malnutrition in Madhya Pradesh is the worst in India. The state figures pertaining to malnutrition show the ominous face of this malady. In Madhya Pradesh the percentage of underweight children is 51.9 whereas the prevalence of stunting and wasting is 48.9% and 25.0% respectively. Stunted growth is a reduced growth rate in human development. Stunted children may never regain the height lost as a result of stunting, and most children will never gain the corresponding body weight. Whereas wasting refers to the process by which a debilitating disease causes muscle and fat tissue to “waste” away. Wasting is sometimes referred to as “acute malnutrition” because it is believed that episodes of wasting have a short duration, in contrast to stunting, which is regarded as chronic malnutrition. The following table lists the districts (though not in the order of severity) which have high prevalence of malnutrition in Madhya Pradesh.

No	District	Underweight	Stunting	Wasting
1	Alirajpur	60.8	52.9	32.6
2	Barwani	65.1	58	34.8
3	Datia	59.6	66.7	21.1
4	Dindori	61.7	50.3	31.6
5	Satna	67.1	66.3	29.5
6	Umariya	66.6	60.3	32.9
7	Sheopur	52.3	64.6	17.9
8	Singrauli	58.8	51.8	34.3
9	Sagar	48.3	61.5	19.2
10	Rajgarh	56.5	46.6	40.2
11	Khargone	58.0	50.6	30.8
12	Mandla	56.5	47.3	29.6
13	Jhabua	57.0	50.3	31.5
14	Dhar	54.4	46.9	33.2
15	Bhind	55.1	63.5	16.0
16	Gwalior	56.6	65.2	21.1
17	Shahdol	56.5	42.1	32.6
18	Shivpuri	55.0	62.0	25.7
19	Shajapur	51.7	43.3	30.1
20	Rewa	53.7	58.3	22.0
21	Katni	55.5	51.5	27.4
22	Khandwa	56.9	45.1	29.8

(Source: Annual Health Survey 2010- 11)

According to the NRHM, which works under the central ministry of health and family welfare, malnutrition among children is most prevalent in Madhya Pradesh. It said that 60 out of 100 children in Madhya Pradesh suffer from malnutrition while the national average is a mere 42. The report published in 2010 report also says that child mortality rate in Madhya Pradesh is 70 out of 1,000 children born while the national average is 53.

Normally malnutrition and other illnesses related to malnutrition affect children who under 5 years of age. The Under-5 Mortality Rate (U5MR) is one of the indicators of the poor health of children below 5 years of age of Madhya Pradesh. IMR denotes the number of infants deaths (age below one year) per 1000 live births. According to the Annual Health Survey (2010-11), the U5MR of Madhya Pradesh is 89 which is worse than Cambodia (88), Pakistan (87), Kenya (84), Ghana (69), Botswana (57), and Bangladesh (41). Female child mortality rate is higher in 35 district comparison to male child mortality. The following table shows the severity of U5MR in Madhya Pradesh:

S.No	District	Male	Female	Total
1	Panna	135	146	140
2	Satna	125	135	130
3	Sidhi	106	131	118
4	Damoh	103	132	117
5	Umaria	116	105	110
6	Shivpuri	94	117	105
7	Dindori	108	100	104
8	Rewa	97	108	102
9	East Nimar	96	107	101
10	Sheopur	96	107	101
11	Vidisha	96	107	101
12	Datia	91	109	99
13	Raisen	94	104	99
	Madhya Pradesh	86	93	89

(Source: Annual Health Survey 2010- 11)

Madhya Pradesh has the highest Infant Mortality Rate (IMR) in India, followed by Orissa (65), Uttar Pradesh (63), Assam (61) and Bihar (61). The IMR of the best performing states are Kerala and Goa is 11 and 12 respectively.

Malnutrition does not affect children alone, even though children die in greater number than adults due to the complications arising from malnutrition. National Family Health Survey (NFHS-2005-06), selected findings of which are given below, shows that adults especially women are equally affected by malnutrition which reflects in their low Body Mass Index (BMI). This survey also throws light on the anaemia prevalence among children in Madhya Pradesh.

Indicator	NFHS-3 (2005-06)	NFHS-2 (1998-99)
Children under 3 years who are stunted (%)	46.5	55.5
Children under 3 years who are wasted (%)	39.5	29.2
Children under 3 years who are underweight (%)	57.9	50.8
Children age 6-35 months who are anaemic (%)	82.6	71.3
Women whose Body Mass Index is below normal (%)	40.1	35.2
Men whose Body Mass Index is below normal (%)	36.3	NA

(Source: National Family Health Survey 2005-2006)

As illustrated by the tables given above, the health and poverty indicators in Madhya Pradesh are extremely poor. The state has the highest IMR in India; maternal mortality is estimated at 310/100,000 live births; and approximately 62% of population are considered to be living below the poverty line. The health outcomes of SC/ST populations and girls/women are worse. Estimates suggest that MP is unlikely to meet the targeted reductions in maternal and child mortality without focused and renewed efforts; the prevalence child malnutrition is high in comparison with the rest of India. Status of Madhya Pradesh in terms of achieving Millennium Development Goal (MDG) on three important aspects related to nutrition is given below;

Status of Madhya Pradesh on MDGs Target Achievements1 of IMR, U5MR and NMR
Indicators	MDG target for Madhya Pradesh	Madhya Pradesh 2007	Madhya Pradesh 2008	Madhya Pradesh 2009	Madhya Pradesh 2010
Infant Mortality Rate (IMR)	39	74	72	70	67
Under 5 Mortality Rate (U5MR)	43	NA	NA	94.2	89
Neonatal Mortality Rate (NMR)	17.7	NA	NA	44.9	44

(Source: Annual Health Survey 2010- 11)

Government Response

The government has functionalized several arrangements for combating malnutrition of rural areas. However, most of these institutional systems remain on paper. Their functionality and capacity to address the massive problem remains questionable. Madhya Pradesh, which tops in malnutrition deaths in the country, has set up over 200 diet and health centres in which, as government claims, more than 26,000 kids have been reportedly cured so far. More often than not, the responses of government to the news on the deaths of malnourished children come as knee-jerk reaction rather than effective and sustainable mechanisms for providing lasting solutions to chronic malnutrition.

The state government had implemented targeted interventions in the past for eradicating malnutrition of children. Madhya Pradesh government conducted the Kuposhan Nirvaran Abhiyan (Malnutrition Eradication Campaign) from 2001 which covered nearly 57 per cent of all children of the state every year for five years. This campaign was implemented for identifying malnourished children and linking them with government-run nutrition services. All panchayats have Primary Health Clinics (PHCs), anganwadis and schools with mid-day meal schemes for providing solution to the malnutrition among children. Despite these vast institutional arrangements and infusion of huge funds under various schemes under the umbrella programmes of Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM), the real success in mitigating the malnutrition crisis remains elusive. 

Solution to the Malady of Malnutrition – How?

The priority for malnutrition response is eradicating malnutrition and prevalence of underweight children under 5. This objective is to be achieved by strengthening communities and functionalizing grassroots level health delivery systems. There is a need to approach malnutrition from both the community and facility angles in its effort to improve the child health status in the state. The major focuses of malnutrition interventions of both government and the voluntary sector should include the following broad areas;

• Promoting health literacy; informing communities about proper child feeding techniques and proper nutrition
• Identifying locally viable, available and developable food sources
• Advocating with the government to adopt innovative approaches and increasing the access to treatment and preventative services
• Working with local organizations in delivering programmes at field level
• Reviving the lost or disappearing indigenous crops, which are proven remedy for malnutrition such as legumes, millets, herbs, etc.

It is widely felt that there is a greater need to address various factors that eventually lead to malnutrition of a child. Malnutrition in itself is a multi-dimensional problem because it is related with the process of socio-political transformation like social behaviour, household livelihood, state services, equality and human rights with dignity. The malnutrition cycle, most often, begins even before the birth of the child. Pregnant women do not get nutrition support due to ignorance and traditional practices. After delivery, mothers breast-feed the child for around 6 months and from then the child does not get nutritional food for normal growth due to household food insecurity. A child requires more attention and supplementary nutrition during the first two years because during this period of age, 80 percent physical and mental growth takes place. But due to poverty they don’t get quality food and after a point, hunger deaths begin.

Therefore, the first step is identifying the factors of malnutrition of communities and tailor-making a remedial system. Malnutrition in India is because of complex set of interrelated reasons. In certain areas, malnutrition occurs not because of lack of food, but a lack of proper nutrition compounded by a lack of education about what constitutes proper nutrition and young child feeding practices. Infant feeding techniques are laced with superstition and misunderstanding. Therefore, this step will involve removing the barriers to behaviour change.

Secondly, effort will have to be made for increasing people’s access to local health delivery systems. This involves sensitizing the masses on the delivery points of health services and functionalizing these points with people’s participation. This also needs to involve mobilizing people along Right Based Approach (RBA) and informing them about their rights on the services of Anganwadi Centre (AWC), Primary Health Centre (PHC), Nutrition Rehabilitation Centre (NRC), etc. Anganwadi centers, a crucial cog in the nutrition support system, need strengthening so that they can meet the needs of the community for identification, treatment, and prevention of malnutrition. Unfortunately most AWCs function only on paper now.

Thirdly, cases of Severe Acute Malnutrition (SAM) need to be identified and linked with referral treatment services. The severely affected regions need to be exhaustively scanned and SAM cases need to be linked with hospitals or NRC and sources of Ready to Use Therapeutic Food (RUTF). The success of intervention to eradicate malnutrition depends on the extent of local solutions. Ethnic and aboriginal communities, the worst affected, have ceased to cultivate crops that were very beneficial for children’s health. However, these crops such as legumes, millets, herbs etc have nearly disappeared largely due to the introduction of cash crops like soybean, cotton etc.

Therefore, the fourth priority will be identifying and reviving the cultivation of local agriculture produces that will offer food security and nutritional support to the people. Vegetable types suitable to MP’s geographic terrain will also be popularized. Examples are Moringa Oleifera or ‘drum-stick’ which is called the natural nutrition for the tropics, and hedge spinach.